Developing of case-importing teaching module-integrated 2D pathology and 3D radiology to improve learning effect in undergraduates of stomatology

doi:10.21203/rs.3.rs-2436316/v1

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Research Article

Developing of case-importing teaching module-integrated 2D pathology and 3D radiology to improve learning effect in undergraduates of stomatology

https://doi.org/10.21203/rs.3.rs-2436316/v1

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Purpose

The teaching concept of integrated curriculum is an important means of medical education improvement, which can arouse students' enthusiasm for learning, enhance the learning effect of basic and clinical subjects, and help students to establish interdisciplinary connection. This study aimed to combine stomatologic pathology-radiology courses with instructional media and to propose a new morphological integrated teaching mode for undergraduate stomatology education.

Methods

In total 84 undergraduates were divided into four teaching groups: traditional (Group T), KoPa WiFi EDU system (Group K), KoPa WiFi EDU-CBCT (Group K-C), and CBCT-KoPa WiFi EDU (Group C-K). Participants received a 2-hour lecture on periapical cysts and sat a theoretical test. Corresponding groups underwent a 4-hour experimental pathology and radiology course on periapical cysts using different teaching methods. Participants repeated the theoretical test with an experimental test. Teaching effects were assessed based on objective and subjective experimental test scores and difference in theoretical test scores.

Results

The results indicated no significant difference in the first theoretical outcomes among four groups (P > 0.05). The second theoretical scores, objective and subjective experimental scores of integrated teaching mode with KoPa WiFi EDU system and CBCT which scored 89.29 ± 4.55, 81.00 ± 8.15, 61.57 ± 5.52 (Group K-C) and scored 87.52 ± 3.44, 80.00 ± 9.22, 58.00 ± 4.44 (Group C-K) exhibited superior teaching effects comparing to traditional teaching mode (scored 72.57 ± 3.84, 69.38 ± 4.91, 48.67 ± 5.54) and 2D teaching mode with KoPa WiFi EDU system (scored 80.43 ± 3.41, 73.00 ± 8.01, 55.67 ± 5.66) (P < 0.05). In the integrated teaching mode, subjective scores were higher in Group K-C (pathology followed by radiology) than in Group C-K (radiology followed by pathology) (P < 0.05). Long-term teaching effect of integrated mode was better than traditional mode (P < 0.05).

Conclusion

The K-C group combined with 2D pathology and 3D radiology in the morphology-based integrated teaching mode was the most superior one for undergraduates’ learning effects.

Dental education

Morphological teaching

Oral Histopathology

Oral and Maxillofacial Radiology

Fused curriculum

Undergraduates of stomatology predominantly study the field of medicine and dentistry for the prevention, diagnosis, and treatment of oral and maxillofacial diseases [1]. Oral Histopathology and Oral and Maxillofacial Radiology are two basic courses in undergraduate education that form a bridge between professional dental clinical and basic medical practice. These courses serve as the foundation of future clinical work and in-depth oral research for stomatologists [2]. However, dental educators are faced with a major challenge, that is, how to improve the interest of stomatology students in basic courses related to dentistry and medical practitioners, the selection of content for inclusion in the teaching process, and the choice of teaching mode to ensure students achieve maximum learning effects [2, 3]. Therefore, exploration of appropriate teaching methods in oral undergraduate education for the cultivation of future dentists is critical.

At present, the traditional exam-oriented education method of ‘spoon-feeding’ unidirectional instillation which combines theory and experiment is still widely practiced in stomatological education colleges in China [2, 4]. Theoretical teaching aims to teach different courses as independent modules separately for students, which precludes knowledge integration and failure to establish a connection in most morphology-based curriculum such as pathology and radiology of a given disease [5]. In addition, deficiencies exist in methodology and equipment of traditional experimental teaching, which causes various problems such as lack of enthusiasm and low classroom efficiency [6–8]. For example, pathology slides are used as observation specimens and optical microscopes are adopted as observation tools in traditional experiment teaching. In the actual classroom teaching process, a teacher can only perform one-to-one tutoring for students via operation under their own microscopes [9–11]. This substantially reduces the learning effect and overall teaching efficiency. Moreover, radiology experiments are predominantly based on X-ray plain films and multimedia teaching. The teaching process does not permit multi-directional and multi-angle spatial changes of the disease and cannot vividly reproduce the three-dimensional (3D) dynamic imaging structures of normal and pathological tissues. Accordingly, students can only imagine the 3D evolutionary process of the disease according to the description of the teacher [12].

With the growing application of digital technology in stomatology education in recent years, novel options have emerged to improve basic experimental teaching modes of stomatology [13, 14]. The micro-digital interactive system allows instant feedback and promotes dialogue in class, which achieves extensive use of resources and effectively solves problems such as poor communication between teachers and students. Additionally, teachers can also gain insight into the deviation and gaps of students’ understanding based on feedback, which will help to modify teaching strategies [15, 16]. The KoPa WiFi EDU system is a digital microscope technology combined with a tablet which acts as a display screen connected to the microscope and terminal for teachers via data transmission by WiFi signal. The Cone Beam CT (CBCT) software overcomes the weakness of 2D plain films such as image deformation and overlapping, and has the functions of plain film import, maxillofacial image formation, and multi-plane 3D reconstruction [17, 18]. This enables an evolution of image display from 2D to 3D, thus improving students’ comprehension of oral diseases [12, 19]. The joint application of these two systems will maximize the utilization of teaching resources in the teaching process and continuous combination from micro to macro, thereby improving the learning effect of students.

This study proposed the following logical relationship in the two morphologically based courses: pathology is the microscopic embodiment of radiology, and radiology is the macroscopic reproduction of pathology. Based on this description, we proposed the P-R (pathology-radiology) teaching method, a new basic stomatologic teaching method combining case-induced pathology and radiology (Fig. 1). First, pathology and radiology manifestations of diseases were systematically explained to students in the form of cases. Pathology and radiology were then combined in experimental teaching through appropriate teaching media, thus forming a systematic understanding of disease.

Participants

In this study, 98 second- and third-year undergraduates from the School of Stomatology Lanzhou University who had not been exposed to oral professional knowledge were selected. After being introduced to the experimental project, they agreed to participate in the study and signed the informed consent form. In total, 84 volunteers were randomly selected from these 98 students using a random number table and were included in this study. The study protocol was approved by the Ethics Committee of School of Stomatology Lanzhou University (No.LZUKQ-2019-25), registered in Chinese Clinical Trial Registry (ChiCTR2200057760, 16/03/2022) and also performed in accordance with the principles stated in the Declaration of Helsinki (Amended by the 64th WMA General Assembly, Fortaleza, Brazil, October 2013).

Research methods

The experimental flow chart is shown in Fig. 2.

Theoretical teaching

Participants received a 2-hour theoretical lecture before study commencement (Fig. 3a, 3b). The first theoretical test was then conducted. The 84 participants were divided into four groups according to their theoretical test scores: traditional (Group T), KoPa WiFi EDU system (Group K), KoPa WiFi EDU-CBCT (Group K-C), and CBCT-KoPa WiFi EDU (Group C-K) teaching groups. As shown in Fig. 4a, no significant difference was observed among the theoretical scores of each group (P = 0.469), which ensured that the average level of theoretical knowledge in each group was at the same baseline level before the experiment. Further, there were no significant differences in gender and region among groups.

Experimental teaching

Different teaching methods were adopted to conduct experimental teaching for the participants of each group. For the traditional teaching group, teachers explained the content of pathological slices and method of analysing plain image films, students then read the films independently, and teachers answered their questions (Fig. 3c). For the KoPa WiFi EDU system teaching group, students read pathological films via the KoPa WiFi EDU system (GuangZhou Ostec Electronic Technology, China) to convert images under the microscope to a tablet in real time, and radiology-teaching transmitted the plain images from the teacher to students via the teacher-student interaction function of the KoPa WiFi EDU system (Fig. 3d). For the KoPa WiFi EDU-CBCT teaching group, students first studied pathological slices using the KoPa WiFi EDU system and then used CBCT (KaVo Dental GmbH, America) to learn image reading (Fig. 3e). For the CBCT-KoPa WiFi EDU teaching group, the teaching system (shown in Fig. 4) was the same as that of the KoPa WiFi EDU-CBCT teaching group except in the reverse order. According to the teaching method of each group, the lecturer covered the teaching content in 2 hours, and the students then studied independently for 2 hours, during which the lecturer and teaching assistants answered questions.

Teaching effect evaluation

After the experimental teaching, the second theoretical test, first objective experimental test, and first subjective experimental test were sequentially performed to evaluate the short-term learning effects of participants under different teaching methods. The third theoretical test, second objective experimental test, and second subjective experimental test were performed to evaluate the long-term learning effects of participants after 3 months. The theoretical test was similar to the first theoretical test, predominantly comprising single and multiple-choice questions. The test of objective questions was based on the identification of key structures in disease pathological slices and plain image films, whereby students were required to fill in the blanks. Subjective questions assessed the slice reading skills of students, whereby students were required to state the result and reason for disease judgement. Standard examples are presented in Table 1.

Table 1

Subjective experimental test score sheet
Scoring items	Score
Pathology
Disease judgement	10
Judgement evidence
● Fibrous cystic wall	5
● Stratified squamous epithelium	5
● Nonkeratinizing epithelium	5
● Epithelium with different thickness and spike	5
● Inflammatory cell infiltration	5
● Cholesterol crystals inside the fibrous cystic wall	5
● Rushton body inside the fibrous cystic wall (sometimes)	5
Overall description fluency	5
Radiology
Disease judgement	10
Judgement evidence
● Apex-centered performance of the affected tooth	5
● Regular shape and different size	5
● Generally 1 ~ 2 cm of diameter	5
● Round or oval in shape	5
● Bone destruction and low density image	5
● Clear shape edge	5
● Dense line image around the cyst	5
Overall description fluency	5
Total	100

Questionnaire

After the test, students were administered a questionnaire survey using a Likert scale [20]. The content of the questionnaire included satisfaction regarding classroom learning and learning effects. The following scale of points was used: 5, very satisfied; 4, relatively satisfied; 3, average; 2, not very satisfied; 1, very dissatisfied.

Statistical analysis

Following data entry, SPSS 26.0 (IBM, Chicago, IL, USA) was adopted for statistical analysis. All measurement data were expressed as mean ± standard deviation. Comparison of means among different groups was performed using a t-test and one-way ANOVA. For the data not conforming to the normal distribution, a non-parameter test was adopted. The level of statistical significance was set at P < 0.05.

Theoretical test results

The results of the first theory test are presented in Fig. 5a. The scores of Groups T, K, K-C, and C-K were 72.52 ± 3.50, 72.48 ± 3.47, 73.71 ± 2.49, and 72.43 ± 2.71, respectively, with no significant differences among groups (P = 0.469). This suggested that the theoretical knowledge possessed by the participants in each group prior to experimental teaching was at the same baseline level, and there was no significant difference in participants’ knowledge mastery (i.e., learning ability).

The results of the second theory test are presented in Fig. 5b. Group K-C obtained the highest score (89.29 ± 4.55), followed by Group C-K (87.52 ± 3.44). There was no significant difference in scores between Groups K-C and C-K (P = 0.141), but both groups obtained significantly higher scores compared to Groups T (72.57 ± 3.84) and K (80.43 ± 3.41) (P < 0.001). In addition, scores were significantly higher for Group K than for Group T (P < 0.001).

The second theory test scores of Groups K-C, C-K, and K were significantly higher than the first theory test scores (Z = -5.558, P < 0.001; t = -15.779, P < 0.001; and t = -7.483, P < 0.001, respectively), but there was no significant difference between the two theoretical teaching scores in Group T (t = -0.042, P = 0.967) (Fig. 5c).

The results of the third theory test are shown in the Table 2. The scores of Group T were significantly lower than those of Group K, Group K-C and Group C-K, where the difference was statistically significant (P < 0.05). In addition, the scores of Group K-C and Group C-K were significantly higher than those of Group K (P < 0.001).

Table 2

Comparison of theoretical score, objective score and subjective score among groups after 3 months
Groups	Theoretical score			Objective score			Subjective score
Groups	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value
T	65.2857	4.61674	< 0.001	61.0476	7.15176	< 0.001	43.2857	5.76318	< 0.001
K	70.0952^a	5.01901		64.5714	8.71534		49.9524^a	5.43577
K-C	77.9524^ab	4.83194		72.0952^ab	9.58073		55.9048^abc	5.04881
C-K	76.4286^ab	5.22084		71.0476^ab	9.13497		52.4762^a	4.97613
Note: a: compared with Group T, b: compared with Group K, c: compared with Group C-K.

Experimental test results

The objective scores of Groups K-C and C-K were 81.00 ± 8.15 and 80.00 ± 9.22, respectively, which were significantly higher than those of Groups T (69.38 ± 4.91) and K (73.00 ± 8.01), with a significant between-group difference (P < 0.05). No significant difference was noted in objective test scores between Groups K and T (P = 0.134) (Fig. 5d).

The subjective assessment results of the film-reading experiment are presented in Fig. 5e. Group K-C obtained the highest score (61.57 ± 5.52), followed by Group C-K (58.00 ± 4.44). Analysis of the two groups revealed a significant difference (P = 0.032), and their scores were both significantly higher than that of Group T (48.67 ± 5.54, P < 0.001). In addition, scores were significantly higher for Group K-C than for Group K (55.67 ± 5.66, P = 0.001) and for Group K than for Group T (P < 0.001).

As is shown in the Table 2, the objective scores of slices and films reading of Groups K-C and C-K after three months were significantly higher than those of Groups K and T, where the difference was statistically significant (P < 0.05), but there was no significant difference between the scores of Group K and Group T (P = 0.193). The subjective scores of Groups K-C, C-K and K were significantly higher than those of Group T (P < 0.001). Besides, the scores of Group K-C were higher than those of Group C-K, where the difference was statistically significant (P = 0.040).

Questionnaire survey results

Based on our observations of classroom teaching and questionnaire survey results (shown in Table 3), the classroom richness and activity were significantly higher for Groups K-C, C-K than for the traditional teaching group (P < 0.05). Learning enthusiasm, teacher-student interaction, and mastery of classroom learning content for Groups K-C, C-K and K exhibited higher satisfaction scores compared to those for the traditional teaching group, but no significant differences were observed (P > 0.05). In the final learning effect satisfaction survey, the learning effect satisfaction of Groups K-C, C-K and K was significantly higher than that of the traditional teaching group (P < 0.05). Attached Table 1, 2, 3, 4 presented the questionnaire items regarding the satisfaction of each group.

Table 3

Questionnaire survey results
Project evaluation score	Groups (Mean ± SD)
Project evaluation score	T	K	K-C	C-K
Course richness	4.07 ± 0.96	4.20 ± 0.41	4.60 ± 0.51^a	4.80 ± 0.41^a
The activity of the class atmosphere	3.60 ± 0.63	3.87 ± 1.06	4.20 ± 0.68^a	4.40 ± 0.63^a
Improvement of learning motivation	3.80 ± 0.77	4.07 ± 1.10	4.13 ± 0.83	4.27 ± 0.70
Interaction between teachers and students	3.67 ± 1.18	3.93 ± 0.80	4.07 ± 0.88	4.33 ± 0.90
Timely mentoring for questions	4.53 ± 0.52	4.60 ± 0.63	4.67 ± 0.62	4.60 ± 0.63
Mastery of the pathology performance	3.47 ± 0.52	3.60 ± 0.63	3.80 ± 0.56	3.60 ± 0.63
Mastery of pathological slices reading skill	3.60 ± 0.63	3.80 ± 0.68	4.00 ± 0.76	3.87 ± 0.64
Mastery of radiology feature	3.87 ± 0.52	3.87 ± 0.64	4.33 ± 0.49^a	4.20 ± 0.56
Mastery of radiological film reading skill	3.60 ± 0.83	3.67 ± 0.72	4.00 ± 0.85	3.87 ± 0.64
Satisfaction of the learning effect	4.13 ± 0.64	4.53 ± 0.52^a	4.80 ± 0.41^a	4.53 ± 0.52^a
Note: a: compared with Group T.

Pathology and radiology afford morphological manifestations of a disease from different perspectives. Based on common morphologic features, we explored a new teaching mode: case-introducing P-R morphology teaching. Herein, the integration of the two morphological teaching methods was realized via the KoPa WiFi EDU system and CBCT, and the short- and long-term evaluation of teaching effects were performed. Our analysis revealed that compared with traditional independent teaching modes, the 2D teaching mode supported by KoPa WiFi EDU system and integrated teaching mode assisted by KoPa WiFi EDU and CBCT, integrating pathology and radiology, achieved superior teaching effects. Concurrently, the questionnaire survey results indicated that learning satisfaction was significantly higher for the two teaching modes than for the traditional teaching mode.

Extensive evidence has highlighted the shortcomings of traditional optical microscope and traditional X-ray in stomatology teaching [2, 12, 21, 22]. Additionally, the traditional teaching mode uses two independent courses, which precludes integration of knowledge by students. The KoPa WiFi EDU system converts the microscopic pathological manifestations of a disease in real time and uses a teacher-student interaction function to facilitate connections between teachers and students. Students can obtain the imaging manifestations of a disease from the teacher independently. Rinaldi et al. [16] reported that the application of the interactive system in the teaching of pathology experiments provided a convenient platform for communication between teachers and students, which mitigated the shortcomings of traditional teaching methods. The application of a digital virtual microscope system in pathology courses in University of Copenhagen has received unanimous praise among teachers and students [11]. Chang et al. [3] demonstrated that students who used virtual microscopes had higher knowledge acceptance rate and better histopathological diagnosis ability compared to those who used traditional microscopes. Another study revealed that virtualized digital radiographic teaching had a greater effect compared with traditional teaching [23]. In addition, the use of teaching media makes teaching courseware well displayed, which improves teaching effectiveness and students’ learning efficiency [14, 22]. However, the teaching method with KoPa WiFi EDU system as the medium facilitates learning of pathologic and radiologic manifestations of a disease on the 2D plane. The introduction of CBCT converts the imaging manifestations of a disease from a 2D plane to 3D space. Zhu et al. [12] proposed that the application of CBCT could help students to establish the concept of 3D images and understand different disease levels from a macro perspective. Moreover, the KoPa WiFi EDU system can be used to understand the microscopic performance at different 3D levels. Our results demonstrated that this hybrid teaching was the best teaching mode.

In the mixed teaching mode, sequential effects play a major role in learning and decision making [24–27]. We found that Group K-C achieved higher subjective scores compared to Group C-K, and the K-C teaching method was identified as the best teaching mode in this study. There is no doubt that students must learn to use the microscope in pathology teaching and to imagine 3D processes of the human body based on 2D slides [11, 28]. In this regard, the K-C teaching method, based on the integration of pathology and radiology, may improve comprehension among students, thereby advancing their subjective understanding of the pathological and radiological features of a disease.

Additionally, Hanrahan et al. [29] reported that the primacy bias merited further evaluation in medical specialties. The primary effects, which advocates that teachers generally place inspirational content at the beginning to improve the quality of teaching and students’ interest in learning, can affect the positive experiences, self-efficacy and attitudes [30]. The KoPa WiFi EDU system on tablets used as an assistant tool for pathological teaching in this study is a common tool in the current information era and is easy for students to master. Therefore, students gain higher self-efficacy when using it in the first step of learning. Prior literatures also reported that social media provides a form of enjoyment for students, which contributes to communication between learners and educators and improves short-term knowledge storage [14]. As a clinical tool, CBCT is initially unfamiliar to students and is bound to be difficult for learning and using compared to the tablet. The teaching mode of 2D pathology followed by 3D radiology may help students to actualise the transition from 2D microscopic pathologic images to 3D macroscopic images, as well as achieve primacy effects in the teaching process with the tablet which is convenient, easily used and has a friendly interface.

Our study has several limitations including a small sample size and use of a single disease. However, this study provides a reference for future basic oral teaching as follows. The integration of two morphological-based courses allows students to better understand the disease, and cooperative teaching at micro and macro levels positively impacts students’ thinking, thereby providing a deeper impression and facilitating students' understanding and mastery of new knowledge. Additionally, the introduction of new systems in the teaching process can greatly enrich the classroom content and improve students' learning enthusiasm and activity. In recent years, the application of virtual digital slicing in pathology teaching has achieved better teaching results compared to digital interactive microscopes [22]. Computer-assisted teaching and AR/VR applications will provide learners with interactive, modular, and personalized tools [31–33]. The incorporation of CBCT into dental education has become an absolute requirement for future dentists to perform diagnosis and treatment plan with 3D imaging [17]. Accordingly, the constraints of microscopes and X-ray plain films may be overcome in the future by introducing 3D reconstruction function of virtual digital slicing and CBCT into basic stomatology teaching to establish an integrated online learning platform for oral diseases, pathology-radiology, and diagnosis.

Based on the P-R teaching concept of curriculum integration, we found that the K-C (2D pathology followed by 3D radiology) teaching method has deepen students’ subjective understanding of the disease, heightened learning enthusiasm and achieved better learning effects. Besides, it provides a magnificent reference for the construction of integrated online learning platform for oral diseases, pathology-radiology, and diagnosis.

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of School of Stomatology Lanzhou University (No.LZUKQ-2019-25) and registered in Chinese Clinical Trial Registry (ChiCTR2200057760, 16/03/2022).

Consent to participate statement: all subjects agreed to participate in the study and publish their identifying information/images in an online open-access publication, and signed the informed consent form.

Consent for publication

All participants provided informed consent for publication.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors report no conflict of interest.

Funding

The study was supported by Natural Science Foundation of Gansu Province under Grant number 20JR10RA591; 20JR5RA258; 20JR5RA150, Teaching Reform and Innovation Project of School of Stomatology, Lanzhou University under Grant number JYXM-2020-20404 and CSA West China Clinical Research Fund under Grant number CSA-W2021-06.

Author’s contributions

Baoping Zhang, Zhidong Zhang, Dingcheng Guo: software, validation, formal analysis, investigation, writing-review & editing and funding acquisition. Yimin Yan, Di Wang: data curation, writing-original draft. Lizhi Lu, Xin Yu: writing-review & editing, visualization. Songhua Su, Kailiang Zhang: supervision, project administration. Jie Zhang, Bin Liu: reviewed the manuscript and provided the conceptualization, methdology and funding acquisition.

Acknowledgements

We would like to thank for all the students’ wonderful cooperation and appreciate projects.

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No competing interests reported.

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Developing of case-importing teaching module-integrated 2D pathology and 3D radiology to improve learning effect in undergraduates of stomatology

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Figures

Introduction

Materials And Methods

Participants

Research methods

Theoretical teaching

Experimental teaching

Teaching effect evaluation

Questionnaire

Statistical analysis

Results

Theoretical test results

Experimental test results

Questionnaire survey results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1