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The global pandemic significantly impacted most areas of the dental profession. Limitations on treatment, footfall in clinical and university centres and social distancing affected our ability to provide patient care and clinical training. This article details how custom 3D-printed training tools were used to mitigate some of the constraints affecting our established simulated orthodontic clinical skills course. The development of the training tools, structure of the course and potential future implications are discussed.
CPD/Clinical Relevance: The article discusses novel training methods that can easily be adopted in a variety of clinical and non-clinical settings.
Article
Clement Seeballuck
The collective healthcare response to the global pandemic is a testament to the continuous spirit of the notion: ‘rethink, innovate, adapt’ – core factors defining the successful continuation of care in light of such dynamic adversity. This adaptive approach was also key in allowing high-quality training of our future colleagues. This article details a novel orthodontic undergraduate simulated clinical skills course implemented in response to restrictions, and how the successful elements can be adopted in a post-pandemic era of clinical training.
Background
In March 2020, the World Health Organization (WHO) declared the novel coronavirus (COVID-19) outbreak a global pandemic.1 The typical routes of transmission were said to be direct via a sneeze, cough and inhalation of small airborne particles, and indirect, via contact transmission.2 Owing to the risk of the virus, the Trustees of the British Orthodontic Society advised that all orthodontic units and practices should stop all non-emergency treatment, consequently affecting clinical training in dentistry and orthodontics.3
Education at universities worldwide was greatly affected by the global pandemic as learning had to be ‘distanced’ and dental schools had to face the challenge of continuing dental education.4 With both the need to reduce footfall in universities and strict social distancing, training space within traditional skills laboratories and clinics became invaluable with an increased demand for simulated exercises to substitute for the limited clinical experience possible. Trainers needed to adapt to the ever-changing environment.
‘The impact of the COVID-19 pandemic on undergraduate dental education has led to new ways of working, different modes of delivery for elements of programmes and, in some cases, revised timelines for progression.’5
Clinical education had become an area of concern among dental students,6 and it became imperative for dental schools to create contingency plans to mitigate the effects of the COVID-19 pandemic. In the early stages of lockdown, a virtual dental curriculum was necessary, with dental schools effectively closed. As restrictions eased, however, blended training methods were developed, adopting the successful elements of the traditional and virtual curricula. Practical simulated teaching could now recommence with limitations due to room capacity restrictions. Additional phantom head learning was implemented to combat the reduced patient footfall in the aftermath of the pandemic. This article details the creation and implementation of an orthodontic simulated training course using HOPE – Home Operational Practice Equipment.
About HOPE
HOPE is a device that was developed as a collaboration between staff and students at the Dundee Dental School as an alternative to the traditional phantom head. Using online computer modelling software and 3D printing, HOPE is planned to enable students to remotely undertake certain exercises analogous to clinical skills for a minimal cost. The development of this was accelerated throughout 2020, and it proved to be useful in meeting some of the unique challenges encountered during the pandemic. Modularity is a core feature of the device, with an array of components available to facilitate various exercises. The unique CADCAM-designed connectors, integrated into the baseplate allow for specialized attachments to be developed for bespoke exercises (Figure 1). The connector is a blend of traditional carpentry techniques with modern printing possibilities, factoring limitations relating to flatbed printers.
Figure 1. Example of a 3D printed malocclusion custom attachment for HOPE
The main advantage to developing stereolithography (.stl) files for the production of educational tools is the ease in which they can be shared as they are considered the global standard for 3D models. Files can be transferred to recipients with a 3D printer internationally, allowing local production of the training tools by students in remote locations. We produced designs that were possible to print predictably on low-cost filament printers. Filament printers, although still specialist equipment, are far less costly and easier to maintain than the resin alternatives. Focusing on filament printers made access more universal, and less reliant on special equipment. Exercise components can be created by ‘stitching’ the connector components with the custom exercise elements, such as 3D dentition scans with specific malocclusions (Figure 2).
Figure 2. The HOPE baseplate designs being used with a traditional model (left device) and with custom 3D-printed malocclusion (right device) for a more advanced case-based training exercise.
Although initially planned for home use, it was apparent that HOPE could be used to retrofit lecture theatres – vacant since the shift towards online classes – into makeshift ‘clinical skills laboratory’ spaces. The simulated training activities possible were, however, limited by the learning environment infrastructure. Exercises requiring suction, rotary instruments and pressurized air or water would not be possible without significant investment and renovation. Furthermore, safety considerations regarding potentially unsupervised activities had to be considered; particulate generating and cutting exercises were not practically viable as these would require close supervision and access to costly equipment and air compressors, high-volume suction and ventilation.
A novel orthodontic training workshop
Pre-pandemic, the Dundee Dental School delivered an orthodontic clinical skills course, where 4th year undergraduate dental students students gained ‘hands on’ experience with bonding of brackets, archwire and module placement, and debonding on phantom heads, as a part of clinical preparation towards treatment and management of orthodontic patients on the undergraduate clinics. On review of this course, it was decided that the bulk of training exercises could be undertaken outside the clinical skills laboratory, with little compromise.
The principal limitation in running the course in less traditional settings was the lack of rotary instruments for post bracket removal debonding, but use of Mitchell's trimmer for removal of composite was an acceptable method to avoid aerosol generation.7 Hence the alternative method was adapted in the design of the course, keeping in line with guidance at the time.
The aims and objectives of the course were to:
Understand components of a fixed orthodontic appliance;
Gain skills in management of simple fixed orthodontic appliances and methods of ligation;
Gain skills in undertaking limited orthodontic appliance emergency procedures.
The revised course also factored in protocols in line with government guidance to mitigate the spread of SARS-CoV-2. Components for the course were printed using materials that allowed the use of alcohol and chlorine-based detergents. There were also strict social distancing and foot traffic plans. Classes were undertaken within lecture theatres, with a capacity of 16 students (Figure 3).
Figure 3. A student set-up for the initial workshop exercises.
Discussion
The revised course delivered training exercises to address the course aims and objectives. The modified approach, now independent from the traditional clinical skills setting, has considerable potential. Similar courses can be delivered in remote locations with minimal tooling investment. The modifiable attributes of 3D printing components also mean that cases of varying complexity can be accommodated, catering for varying levels of trainees, such as core trainees, or as a pre-clinical exercise for specialty registrars.
As the devices are considerably smaller and lighter than a traditional phantom head, multiple devices are still portable with minimal logistical considerations. There is potentially a role for delivering small group interactive workshops in a similar fashion with regards to continuing professional development.
HOPE has also been used in further applications for orthodontic skills development. An orthodontic colleague was provided with a custom home kit, with more challenging malocclusion exercises during his recovery from severe and long-term SARS-CoV-2. The feedback from this was very positive. Providing the kits for home use allows the user to practice at their own pace in a comfortable environment. Similar analogue exercises could potentially be developed for clinicians in other specialties.
Most recently, the orthodontic exercise kits have been used to train healthcare providers on the remote island of Tristan da Cunha (Figure 4). Tristan da Cunha has close links with Dundee, and orthodontic cases are planned remotely in conjunction with the Dundee Dental School and a Hospital consultant. This demonstrated the utility of the devices as training tools in locations with limited resources, and highlights the potential for tackling barriers to accessing dental training.
Figure 4. The team training with HOPE in Tristan da Cunha.
It is crucial, however, to recognize the limitations with the HOPE device. In order to keep the design reliable, and at a minimal cost, there are no moving parts in our current design. Thus, there is limited ability to assess occlusal relationships. There are basic indicator lines incorporated into the model bases that simulate occlusion when aligned, but these are of limited value. Additionally, the device sits on whatever flat table/surface is available. This is unlikely to be adjustable and will not be analogous to a dental chair. 3D printing time can also be quite long, depending on the printers available, and the process is reliant on having a sufficient knowledge base to manipulate and print files. Creating instructions on how to replicate and print still prove to be rather complex, and users also need to know how to troubleshoot their printers.
Conclusion
As education moves further into the realm of blended online learning, initiatives that allow for clinical skills training remotely will almost certainly take more of a prominent role. This course demonstrated several key features that can be built upon. Similar exercises can be undertaken even more remotely, with the trainee at home, being appraised remotely. As digital technologies continue to develop, it may eventually be possible to combine 3D printed devices with mobile applications to use principles of mixed reality – a blend of tactile tools within the realm of virtual reality.
The next phase of this project is to evaluate the efficacy of these training tools compared, and supplemental, to the traditional courses for achieving the learning outcomes. We intend to undertake a study to validate HOPE as a training tool for orthodontics, along with other applications.
