Keywords typhodont - conservative dentistry - preclinical - augmented reality - virtual reality
Introduction
Dentistry is a blend of surgery with medicine. It focuses more on surgical treatment
rather than relying on medicinal methods. These surgeries involve physical removal,
repair, or adjustment of the affected organs and tissues via the means cutting and
manipulating structures to restore their function. In dentistry, dental caries is
the most frequently encountered disease that still remains the prime cause of tooth
ache and decay globally.[1 ] Aside from caries, tooth trauma, injuries, and developmental flaws can all cause
a disruption in the normal morphology of the tooth. To deal with and manage such situations
in clinical practice, aspiring dentists must have the knowledge, expertise, and abilities
to diagnose, treat, and manage dental cases involving caries, trauma, or any type
of functional or acquired disability involving the teeth.[2 ]
Since cavity preparation or cavity cutting is an irreversible process,[3 ] a dentist must have specialized skills designed to handle the carious lesions which
necessitate extensive hands-on training prior to handling patients.
The dental curriculum consists of preclinical exercises designed to prepare students
to perform the most exemplary surgical procedure on any human. Mannikins of humans,
tooth and head, face and neck region for dentistry, which simulate the human body,
are typically used in these exercises. Every future surgeon must be able to work with
their hands. These preclinical exercises help to achieve them. Thus, it is critical
for every student who aspires to be a surgeon to not only perform but excel at these
mannikins because they will soon be replaced by patients with whom the person must
excel.
Typhodont are simulated tooth models depicting the tooth morphology and to a very
limited extent, its anatomy.[4 ] These are the types of patient simulators that are currently utilized in the majority
of dentistry schools all over the world. They consist of ivory teeth in which the
preclinical students perform their cavity preparation with the help of attached manikins.
This kind of process aids in introducing trainees to the correct operating procedures
that must be followed when treating patients. However, one of the major drawbacks
or limitations of typhodonts is the clinical diversity in tooth morphology, differences
in dentitions and occlusions, and preclinical students' performance on typhodont that
cannot clearly reflect their performance on a patient in an actual clinical setup.[5 ]
Studies done previously found that typhodonts play an important role in the students
theoretical curriculum.[6 ]
[7 ] Two other researches done revealed that typhodonts are a poor predictor of students
clinical performance.[5 ]
[8 ] All these studies done focused mainly on evaluating the role of typhodonts in routine
prosthetic crown cutting. There still exists dearth of literature on the assessment
of efficacy of typhodont preclinical conservative dentistry exercises in routine clinical
practice. The aim of this article is to gauge this literature gap and understand the
attitude of dental students and dentists toward the efficacy of preclinical conservative
dentistry typhodont exercise in the routine clinical practice.
Materials and Methods
This study was a cross-sectional survey of dentists and dental students from the Navi
Mumbai region. Prior to the start of the study, the Scientific Review Committee (SRC)
and the Institutional Ethics Committee (IEC) approval was obtained (Protocol No.:
IEC357072022 Version No.: 001). A detailed questionnaire was developed, with questions
designed to gauge the individual's attitude and perception of typhodont exercise during
the preclinical years. Validation of the questionnaire was done by 10 subject experts.
The questionnaire had 23 close-ended questions. Gender, area of work/study, qualification,
and other basic socio-demographic questions were asked, followed by attitude and perception
questions. There were nine questions with four different variables such as “yes,”
“no,” “maybe,” and “can't comment.” Eight Likert scale questions ranging from “1”
(least relevant) to “10” were asked (most relevant). The final question was an open-ended
question asking for suggestions concerning how to conduct the typhodont exercise ([Fig. 1 ]).
Fig. 1 Questionnaire Form used.
Participants were those who availed informed consent for the study. The following
individuals met the inclusion criteria: Endodontists, other dental specialists, general
dentists, postgraduate (MDS) students, undergraduate dental students from the third
year onwards, and interns students in their first and second years of BDS were excluded
from the study because they had not yet had any clinical experience. The questionnaire
was distributed via electronic means such as WhatsApp and email. To avoid errors in
data quality, participants were asked to respond immediately. Confidentiality of the
participants was maintained
Statistical Analysis
Data collected was compiled on a Microsoft (MS) Office Excel Worksheet and subjected
to statistical analysis using an appropriate package like Social Package for Social
Sciences (SPSS). Collected data was divided into two groups: group 1: dental students
and group 2: dentists. Descriptive statistics like frequency (n ) and percentage (%) of categorical data, mean and standard deviation of numerical
data in each group were calculated. For comparison of data, chi-squared test was used.
Responses collected on Likert scale were coded as numerical and the comparison was
done using Mann–Whitney U test. Keeping α error at 5% and beta error at 20%, power
at 80%, p -value less than 0.05 was considered statistically significant.
Results
A total of 250 responses were invited as well as collected; thus, a 100% response
rate was achieved. Of this, 149 (59.6%) were dental students representing group 1.
The remaining 101 (40.4%) were dentists representing group 2, who responded to the
questionnaire ([Table 1 ]).
Table 1
Frequency and percentage distribution
Dental students
Dentists
Male
35 (14%)
40 (16%)
Female
114 (45.6%)
61 (24.4)
[Table 2 ] shows comparison of the responses for the questions with variable: “yes,” “no,”
“maybe,” and “can't comment.” The comparison was done using chi-squared test. In this
study, 154 (61.6%) participants (85 dental students and 69 dentists) responded that
it is better to perform the preclinical work on extracted teeth rather than on typhodont.
Two-hundred five (82%) (127 dental students and 78 dentists) participants agreed that
the exercise allowed them to get accustomed to various essential dental equipment.
One-hundred eighty-two (72.8%) participants (104 dental students and 78 dentists)
responded stating that the exercise helped them get oriented to the operating position.
Table 2
Responses for attitude and perception toward typhodont exercise
Questions
Options
Groups
Total
p -Value
Dental students
Dentists
Did you undertake any typhodont exercise during your preclinical years of BDS?
Can't comment
0
0
0
0.306#
Maybe
0
1
1
No
1
2
3
Yes
148
98
246
While reviewing the theoretical content, did the typhodont exercise help in easing
the learning and understanding process?
Can't comment
1
2
3
0.811#
Maybe
19
13
32
No
1
1
2
Yes
128
85
213
Has it helped you in choosing the correct and appropriate treatment plan for your
patients?
Can't comment
12
11
23
0.048*
Maybe
34
32
66
No
26
24
50
Yes
77
34
111
Has it helped you in determining the restorative material for your patient's treatment?
Can't comment
9
7
16
0.096#
Maybe
27
18
45
No
36
38
74
Yes
77
38
115
Has it allowed you to get oriented to the proper operating position while treating
patients?
Can't comment
7
2
9
0.519#
Maybe
15
8
23
No
23
13
36
Yes
104
78
182
Has it allowed you to get accustomed to various essential dental equipment?
Can't comment
3
2
5
0.335#
Maybe
12
11
23
No
7
10
17
Yes
127
78
205
Was the exercise helpful in obtaining the initial dentin depth?
Can't comment
4
5
9
0.242#
Maybe
30
15
45
No
27
27
54
Yes
88
54
142
Have you ever performed restorative procedures on extracted teeth?
Maybe
2
1
3
0.000**
No
76
2
78
Yes
71
98
169
Do you think that it is better to perform the preclinical work on extracted teeth
rather than typhodonts?
Can't comment
13
8
21
0.292#
Maybe
39
17
56
No
12
7
19
Yes
85
69
154
# represents statistically non significant difference (p > 0.05)
* represents statistically significant difference (p < 0.05)
** represents statistically highly significant difference (p < 0.01)
[Table 3 ] shows comparison of the responses collected using Likert scale coded as numbers
(score). The analysis was done using Mann–Whitney U test. The responses saw a statistically
highly significant difference (p < 0.01) with higher values in group 1 (dental students) for the question asked for
relevance of exercise in clinical postings and clinics (mean value: 8.07 for dental
students and 7.85 for dentists). In regard to simulation of gingiva, mean value was
5.53 for dental students and 4.74 for dentists (p < 0.01).
Table 3
Responses of Likert scale coded as numerical (score)
Group
n (score)
Mean
SD
SE mean
t -value
p -Value of t -test
On a scale of 1 to 10, how inclined were you toward typhodont exercise?
1
149
8.09
1.633
0.134
1.379
0.169#
2
101
7.77
2.044
0.203
On a scale of 1 to 10, how much did it help you during clinical postings?
1
149
8.07
1.697
0.139
0.972
0.332#
2
101
7.85
1.884
0.187
On a scale of 1 to 10, how accurate has the typhodont exercise been in simulating
a patient's mouth?
1
149
6.72
1.903
0.156
0.932
0.352#
2
101
6.49
1.993
0.198
On a scale of 1 to 10, how accurate is the simulation of nature of the gingiva?
1
149
5.53
2.398
0.196
2.654
0.008**
2
101
4.74
2.152
0.214
On a scale of 1 to 10, how much confidence did you gain to treat a patient while performing
clinical procedure on a typhodont?
1
149
7.20
1.896
0.155
1.986
0.048*
2
101
6.69
2.111
0.210
On a scale of 1 to 10, how much confidence did you gain while performing clinical
procedure on a typhodont that you won't expose the pulp while treating a patient in
the clinic?
1
149
6.52
2.350
0.193
3.097
0.002**
2
101
5.56
2.439
0.243
On a scale of 1 to 10, how confident were you while performing on a typhodont that
you have reached the desired and required depth while treating a patient in the clinic?
1
149
7.07
1.921
0.157
3.135
0.002**
2
101
6.21
2.434
0.242
On a scale of 1 to 10, how strongly do you believe that typhodont preclinical exercise
helps an individual get used to the restoration procedure while also considering the
associated hard and soft tissues of the oral cavity?
1
149
6.99
2.045
0.168
2.611
0.010*
# Represents statistically non significant difference (p > 0.05).
* Represents statistically significant difference (p > 0.05).
** Represents statistically highly significant difference (p > 0.01).
The last part of the questionnaire was an open-ended question asking for suggestions
in regard to overall conductance of the typhodont exercise and its future prospects.
The respondents answered suggesting the continuation of typhodont exercise along with
incorporation of extracted teeth exercises with more in-detailed pathological application
or real-life dental caries simulation into the artificial or extracted tooth. Use
of augmented reality (AR) and virtual reality (VR) along with haptic technology was
also suggested.
Discussion
The purpose of our study was to understand the perception of dental students and dentists
toward typhodont exercises its relevance in the clinical practice. A study done by
Gartenmann et al concluded that preclinical exercise, irrespective of the field, is
sufficient to implement skills needed to prepare the students for the clinical environment.
However, incorporation of newer and innovative methods is necessary.[9 ]
Laboratory-based practical is an effective tool used in conjugation with the theoretical
lectures.[10 ] This study showed that majority (85.2%) of dental students and dentists felt that
the preclinical exercises help in understanding the theoretical content. Similar results
were obtained by Kabra et al where 60% of the students responded were found to ascertain
standard of knowledge-based questions.[6 ] Study done by Gul et al had similar results where 80% of the participants believed
the same.[7 ] Velayo et al also found in their study that the preclinical training on typhodont
models and in the classroom was associated with clinical performance of the students.[11 ]
Transition from preclinical to clinical training is very challenging.[12 ] It is critical for students to gain confidence in their ability to treat patients.
In this study, it was projected that majority of the dental students and dentists
believed that they gained enough confidence to treat the patient in clinics (mean
score: ∼7). Similar results were obtained in the study done by Kabra et al where 94%
students stated that the exercise helped them in boosting their confidence and treat
patients more efficiently.6 In this study, most of the dental students and dentists responded that the exercise
helped them during their clinical postings (score: 8) which indicates its efficacy
in routine clinical practice. However, studies done by Nunez et al and Curtis et al
suggest that preclinical exercises are not an indicator of clinical success.[5 ]
[8 ]
Prior to the introduction of typhodont, extracted teeth were preferred for the preclinical
exercises. Extracted teeth are superior to typhodont models in terms of texture, morphology,
overall tooth anatomy, and radiodensity that lacks in the typhodont models.[13 ] In this study, a total of 154 (61.6%) dental students and dentists believed that
it is better to perform preclinical exercise on extracted teeth rather than typhodont
models. This was similar to a study done by Smitha et al where 75% of the students
preferred extracted teeth against typhodont teeth. However, due to various factors
like unavailability and inability to procure healthy and workable extracted teeth
and possible cross infection risks, typhodont seem to serve the purpose without hindering
much of the learning.[14 ]
The main objective of preclinical typhodont exercise is to simulate a clinic-like
atmosphere. In this study, it was pointed that the accuracy of typhodont models in
simulating the oral cavity was just slightly accurate (mean score: ∼6) while for simulation
of gingiva and the associated hard and soft tissue was just accurate (mean score:
∼5) suggesting scope for betterment in regard to the overall simulation of the oral
cavity. The results obtained were similar to a study done by Haralur and Al-Malki
where 82.5% suggested improvements in the simulation ability of the typhodont models
in respect to the periodontium, tongue, and the surrounding hard and soft tissues.[15 ]
In the final question of this questionnaire study, respondents were asked to make
suggestions about the overall conductance and future prospects for the typhodont preclinical
exercise. Some of the common and relevant suggestions were selected that include using
extracted teeth alongside traditional typhodont teeth. Incorporation of simulated
dental caries in the teeth for preclinical exercises was also suggested. Many of the
respondents suggested using AR, VR and haptic technology. AR is a type of technology
that combines a real and virtual environment to provide an interactive experience.[16 ] VR refers to a computer-simulated environment.[17 ] Haptic technology, which is a more recent form of technology, involves tactile sensation
while interacting with computer-generated objects.[18 ] Khalaf et al have stated that all these technologies have a potential to improve
the current state of learning and performance of undergraduate students during the
preclinical years. These tools can be used as an adjunct complementing the currently
employed methods.[19 ]
However, there are certain limitations pertaining to this study that can serve as
future prospects. A larger sample size to evaluate a larger population regarding the
same is imperative. Also, there is a need for researches focused on evaluating the
student's performance on typhodonts used in preclinical conservative dentistry with
their performance in patients. This can give an in-depth and detailed understanding
of the efficacy of the typhodonts in the preclinical conservative dentistry curriculum.
Studies should be undertaken to assess the usability, efficacy, and accuracy of newer
technologies like AR, VR, and haptic technology with respect to conservative dentistry.
Conclusion
It is critical to solicit feedback from both dental students and dentists to keep
the curriculum up to date with the current educational and practical landscape. According
to the findings of this study, the majority of dental students and dentists prefer
typhodont exercise at the preclinical level to become acquainted with surgical procedures
before beginning clinical postings and attending patients. According to the responses
from the current study, the typhodont exercise allows an individual to become oriented
to chair positions, handle surgical instruments, and gain confidence in performing
the clinical procedure. However, simulation of gingiva as well as other oral hard
and soft tissue should be improved. Use of typhodont in association with AR, VR, haptic
technology, and the use of typhodont along with extracted teeth can prove to polish
the current state of preclinical curriculum for conservative dentistry.
