2.1 Pre-clinical Classes
Both of the University of Toronto and the Zhejiang University temporarily closed the faculty or the school in response to the infection prevention measures announced by the administrative authorities,10-13 when the local epidemic situation was exponentially deteriorating. All the pre-clinical classes were transferred to an online mode via established or establishing online platforms respectively, in assistant with other software, applications and education management systems.
On March 16, the University of Toronto Faculty of Dentistry temporarily suspended all pre-clinical classes for DDS (Doctor of Dental Surgery), IDAPP (International Dentist Advanced Placement Program) and graduate students, including didactic classes, laboratory training，in-person lectures and seminars, except one pre-clinical practical test of Prosthodontics on March 16 and a few small group seminars for graduate on March 19. (Figure 1)
Since then, the faculty have been delivering all the didactic classes, quizzes, group discussions, and seminars online through an established online teaching and learning system Quercus,14 which is powered by the Canvas learning management system.15 Quercus was officially put into use across the university’s three main campuses in Sep. 2018,15 and then has been used as a common helpful supplement to the daily education activities throughout the campus for almost two years. At the contingent closing of the faculty, the well-established Quercus was changed into the main field of teaching activities. With customized instructor and student interfaces and the course materials deposited during the last two years, such a quick shift in teaching mode posed little challenge for both the instructors and the students in term of the technique. However, there still was a learning curve for both instructors and students to “talk” to a screen instead of real persons. In addition, not only the conference module of Quercus, but also other conference applications, such as Skype16 and Zoom17, were used separately or in various combination during the online teaching process. Beginning the week of April 6, term tests were resumed and carried out remotely through Quercus, and final exams for DDS students took place at originally scheduled time via ExamSoft.18 For invigilation, the students were asked to run Zoom on their cell phone simultaneously, so that one invigilator could watch 20 students in the exam.
Since the epidemic in mainland China were approaching the climax, the Zhejiang University School of Stomatology postponed the students’ return to campus after the Spring Festival holiday. Online classes started on February 24, the scheduled starting time of the spring term. Currently, even after students have returned to the campus in organized groups between May 4 and 10, online course delivery is still continuing. (Figure 2) Online delivery is carried out mainly through two platforms: Ding Talk19 and Learning in ZJU version 2.0.20 Ding Talk is a kind of live video conferencing, on which live lectures and seminars can be held and videoed, then the videos are uploaded to the newly-developed Learning in ZJU version 2.0 web platform. The videos are accessible for the students to review and will be edited into MOOC in the future. After-class questions and discussions are done in Ding Talk, while tests, quizzes, homework assignments, and the online mid-term exams are conducted through the Learning in ZJU version 2.0. Besides live lectures, streaming videos pre-made by the Zhejiang University and published in the Chinese University MOOC website21 are also utilized. In term of invigilation of the online examination system, strict rules have been set for the mouse pointer tracking in the Learning in ZJU version 2.0, briefly speaking, once the mouse pointer controlled by the student leaves the examination page more than twice, the exam interface will close automatically. At the same time, two invigilators are arranged to supervise fifty students via a real-time video call in Ding Talk.
The Learning in ZJU version 2.0 is developed on the base of tronclass platform in Nov 2019 and was first put into use in the dental education in Jan 2020, the time that was in the climax of the COVID-19 pandemic in China. Due to the developing nature of the Learning in ZJU version 2.0, the instructors and student volunteers have been active helpfully in building up and improving the online education platform, conducting trial lectures and debugging to ensure its quality and efficiency. More and more learning materials have been uploaded into the online platform as the online courses are going on. More and more functions have been built into it, including the statistical analysis of the learning records of the students and the portable version in smartphones, which is similar to the counterpart of Quercus.
2.2 Pre-clinical lab training
The Pre-clinical lab training of the two universities were suspended along with the didactic classes. The University of Toronto Faculty of Dentistry plans to make up these lab classes in the future, on condition that the local epidemic will settle down and the students are allowed to attend school. (Figure 1)
The dental students of Zhejiang University also had the pre-clinical lab training postponed for about three months. The instructors of the Periodontology attempted to demonstrate practical techniques via live video, and even a portion of the practical test was completed through video. However, the off-line practical training and tests are still arranged in the future. In supplement to insufficient lab training, some lab hours were assigned to reviewing literatures. Currently, as the students have returned to campus, condensed and supplementary laboratory training have been provided for both the undergraduate and graduating class students since May 26. (Figure 2)
In according with the change of teaching methods, the assessment methods were adjusted.
The University of Toronto Faculty of Dentistry developed a new examination and task schedule for the term tests of various subjects. Some instructors proposed to change the evaluation formula of courses or term grade points to reduce the number of term tests, such as more weight or credits on daily performance, homework, online active response or final written exam. All the adjustments to the assessment method would not be approved until most of the student voted to accept them in advance. An optional Credit/Non Credit grading system was also implemented for some courses，providing the students an alternative between keeping grades or switching them to the Credit/Non Credit.
The Zhejiang University School of Stomatology also adjusted the composition of the final grades, for example, taking the literature reviewing reports and online oral presentations as parts of the daily assessment. The fulfillment of self-studying MOOC videos was also included. Similarly, the students’ consent was one of mandatory prerequisites to adopting these adjustments. A final written exam of the graduating grade was carried out in July, while no practical assessment was required for this grade. Due to the strict policy of Zhejiang University in terms of the control of the repetitive ratio and the potential risk of exam leak, the questions of the written exam were not pulled out of any standardized databases. However, in contrast to the number of four students failed in 2019, all the graduating students this year passed the written exam. This may indicate, at least as far as the theoretical and didactic part is concerned, the quality of the dental education was not compromised during the pandemic.
2.4 Clinical Activities
According to the announcement by Royal College of Dental Surgeons of Ontario (RCDSO) on March 15,22 it was strongly recommended that all non-essential and elective dental services be suspended immediately and that emergency care be maintained in dental clinics, which had the necessary safety precautions and personal protective equipment (PPE) in place. Remote patient screening was also suggested prior to patients’ referral to the emergency room.
In the University of Toronto Faculty of Dentistry, all patient care service in the clinics have been suspended since March 16, exception for emergency care for the students’ own patients or immediate post-operative care. The graduate specialty residents must coordinate with their program directors about the clinical emergency cases before providing any service under supervision. As of April, only a small number of approved essential personnel were working at the dentistry building, continuing to provide emergency services and oral pathology biopsy services to patients. The elective dental treatment is expected to be resumed as early as July 6, if the pandemic will settle down. (Figure 1)
The range of dental services in the Affiliated Stomatology Hospital of Zhejiang University varied in accordance with the national and local epidemic situation. (Figure 2) Following the instructions of the National Health Commission of PRC, only emergency service was offered at its headquarters from January 31to March 1. As the official epidemic prevention level went down, some dental services were resumed under the strictest PPE controls in the headquarters on March 2, but ultrasonic scaling, implant surgeries and tooth preparation with high-speed rotatory instruments were still forbidden. On the same day, both the two divisions re-opened for emergency services. In order to serve more patients, night shifts have been arranged since April 26. Full range of dental services have been available in the headquarters since May 19. However, by now, only online-booked patients were allowed to visit the hospital.
Strict preventive measures have been taken in the Affiliated Stomatology Hospital of Zhejiang University. Every staff member, including the dental workforce, administrative staff and logistics sections, must be negative in the COVID-19 nucleic acid test prior to his/her return to work. No one is allowed to enter the hospital, unless a mask is on, the body temperature is lower than 37.3°C/99.1°F, and the Health QR code is green. The Health QR code is launched by the Chinese application Alipay aiming to track people's real-time health conditions and other information related to the epidemic, including the contact and travelling history. Negative COVID-19 nucleic acid test result is mandatory for inpatients before admission. More separate operating rooms have been isolated and prepared for the high-risk treatments, such as aerosol generating procedures (AGPs). Strict PPE standards have been executed throughout the hospital with consideration to the infection risk during the various treatments.
Graduate students who live in Zhejiang province were allowed back to clinical practice according to their own wishes as early as April 1. Graduate students returning from other regions and all the undergraduate students went through fourteen-day quarantine. The nucleic acid test results must turn out negative before any of these students resumed clinical practice. Undergraduate students in the graduating class had been in internship rotation since last year, but their remaining rotation were transferred to laboratory practice on phantoms and typodonts. In plus their absence during the temporary closure of the campus, there will be a total of five-month loss of clinical practice from February to their graduation at the end of June. Considering these students are in a “5+3” consecutive dental program, proper modifications in the three-year graduate period may be a remedy for the loss of clinical rotation during the five-year undergraduate period, but no specific plan has been raised up yet.
2.5Graduation and graduate degree defense
For the DDS4 students at University of Toronto, their graduate degree defenses were done online, and a virtual convocation and award ceremony was held on June 5. The Licensing were postponed due to the pandemic.
For dental students in the graduating year of Zhejiang University, the graduate assessment schedule includes two steps: written examination and clinical rotation assessment. An on-site written examination was held on June 11, but the clinical evaluation is missing. In March, a few graduate degree defenses of PhD were done online, but the on-site defenses of graduate residency were done during May 26 through May 29.
Despite restricted access to the research laboratories, the University of Toronto Faculty of Dentistry has conducted the scholarly activities as much as possible. In April, a small number of their labs were approved to conduct essential research, including a COVID-19-related investigation. The faculty are planning to restart the research that cannot be done remotely with a gradual approach. On May 8, the faculty announced the cancellation of summer research program 2020, an annual event through which the undergraduate students can gain hands-on research experience in basic, clinical and public health research. (Figure 1)
In the Zhejiang University School of Stomatology, the research labs were locked down on February 5. Only one staff was appointed to inspect the laboratory and maintain the machinery weekly. The research laboratory partially reopened on February 25, and were restricted to the access of maximum fifteen faculty or staff members each day. Considering the research continuity and the need of graduation, the laboratories began to accept the application of graduate students on March 17. Priority was given to those who live locally or had been through home quarantine with negative nuclear acid testing and no COVID19-related symptoms. Although the upper limits expanded to thirty persons per day, undergraduates were not approved at that time. Since May 25th, the research laboratories have been accessible to all the graduate students and undergraduate students who take part in the research work. (Figure 2)
The University of Toronto Faculty of Dentistry offered an information guide on COVID-19 on its website.23 Scholarly resources on COVID-19 were compiled by the University of Toronto Dentistry Library and other medical libraries worldwide to help students better understand the rapidly evolving evidence sources and help them with decision-making in the future. From this point of view, the resource update and information integration of Zhejiang University still needs to be improved.
The University of Toronto encourages students experiencing difficulties during this special period to seek the help of teachers and faculty through the My Student Support Program (MYSSP) or the Good2Talk platform; 24 The MYSSP provides students with immediate and/or ongoing confidential 24-hour support for any school, health, or general life concern.25 Good2Talk is also a platform that provides confidential psychological support. Besides, the faculty members and staff can access support through the Employee & Family Assistance Program (EFAP).26
The faculty also organized online staff-student meetings to discuss about student concerns. Under the pandemic circumstance, students of the faculty also supported each other through a series of online activities. They started to use the Zoom to send their weekly class-wide conference calls, and they exchanged messages, resources or communicated the progress of test preparation. On April 7, DDS1 class organized an online talent show where they shared skills or showed off hobbies. Moreover, the Dental Students’ Society hosted the annual feel-good DSS Awards Night to present awards and thanks to instructors and faculty members and students. Online contact during this special period is of great significance to everyone engaged.
After the outbreak of COVID-19 in mainland China, the dental students in the Zhejiang University School of Stomatology witnessed the countless sacrifices of people’s lives, especially the medical workforce. Facing the unprecedented impact on the public health system, the dental students were home staying merely as a member of the family and community to cooperate with the epidemic prevention work, but not as future medical workforce. Not until online courses began at the end of February, did the students reconnect closely with their teachers and classmates. A couple of online lectures in the topic of infection prevention in dental health care were arranged to prepare the students for clinical practice in the new normality.
2.8 Connection with Community and Society
The University of Toronto Faculty of Dentistry made decisions to support the health and well-being of the community by donating PPE, while retaining a needed core supply. In April, they sent out their three general anesthesia machines to local hospitals so that the ventilators can be utilized for patient care.
To relieve the load of the hospital, the Affiliated Stomatology Hospital of Zhejiang University provided free online consultation to the public.
2.9 Student Feedback
In the University of Toronto, dental students’ responses to the distance learning diverged a lot. For examples, some students reported little difference between the online mode and the traditional one, while some preferred to ask questions at any time during live classes and get answers in time, and some others complained that they would be easily distracted during online learning. Worries about the progress of the pre-clinical labs were quite common, and anxiety was expressed by those students who had not finished all the clinical cases or earned graduating credits. In contrast, some students took this period as an opportunity to connect with other dental professionals from different places by participating in free dental continuing education courses offered through online platforms.
The dental students of Zhejiang University were basically satisfied with the quality and efficiency of online courses delivery, and they cherished more chances to make personal presentations. A student mentioned that the additional current and topical literature review was very helpful for the inspiration of critical thinking and evidence-based clinical decision. Besides, the writing skills was also improved. Opposite views included that remote collaboration within groups was inefficient, and the demonstration via videos was not clear and the assistance of an animation or illustration was in need. Similar to the students at the University of Toronto, they were worried about the sub-qualified study at home and the lack of laboratory training. For the graduating class, the absence of five-month clinical rotation was regarded as a big loss, but the remedy during the following three-year graduate and resident period seemed helpful to relieve the anxiety.