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Citation: Keppel Hesselink JM, Kopsky DJ (2018) Neuropathic pain due to chronic idiopathic axonal neuropathy: fast pain reduction after topical phenytoin cream
application. Open J Pain Med 2(1): 009-014. DOI: http://doi.org/10.17352/ojpm.000009
Medical Group
DOI: http://dx.doi.org/10.17352/ojpm
Research Article
Evaluation of an interactive e-learning
module “Toothache Clinic” for
delivering information on dental pain:
a prospective cohort study
Maria Giraki1, Michael Kann2, Puria
Parvini3, Karina Obreja3, Tugba
Zahn4, Stefan Rüttermann1, Susanne
Gerhardt-Szep1*
1Department of Operative Dentistry, Carolinum Dental
University-Institute GmbH, J.W. Goethe University,
Frankfurt am Main, Germany
2Dental offi ce, Mainz, Germany
3Department of Dental Surgery and Implantology,
Carolinum Dental University-Institute GmbH, J.W.
Goethe University, Frankfurt am Main, Germany
4Department of Prosthodontics, Carolinum Dental
University-Institute GmbH, J.W. Goethe University,
Frankfurt am Main, Germany
Received: 29 November, 2018
Accepted: 28 December, 2018
Published: 31 December, 2018
*Corresponding author: Dr. Susanne Gerhardt-Szep,
Professor, MME, Department of Operative Dentistry,
Carolinum Dental University-Institute GmbH, J.W.
Goethe University, Theodor-Stern-Kai 7, Frankfurt am
Main 60590, Germany, Tel.: +49-69-6301-7505;
E-mail:
https://www.peertechz.com
Introduction
The diagnosis and treatment of dental pain is one of the
everyday and nevertheless most important tasks of both
dentists and dental students [1-5].
The suffering of a patient with dental pain is usually
considerable, which is why the importance of a correct diagnosis
together with appropriate therapy cannot be overestimated. The
acquisition of competence in this fi eld of dentistry is of great
importance and in only very few cases can actually take place
through direct patient contact during the course of studies.
A solid education before the fi rst patient contact is therefore
important for all participants [6-9]. It is diffi cult to convey
the necessary skills in the form of traditional lectures, because
clinical skills, such as the individual preparation of a pain
anamnesis, and even the implementation of a special therapy,
depend on numerous factors. In this context, the worldwide
experience of recent years with e-learning, especially in the
fi eld of medicine, has shown that interactive, case-based
patient simulations are an excellent tool for training clinical
skills such as the acquisition of diagnoses from fi ndings [10-
14]. In addition, there are further advantages of e-learning
courses which, with the appropriate concepts and didactics,
can impart a similar amount of knowledge as conventional
classroom teaching [15]. This is both time and cost effective, as
well as much more variable in the presentation of the teaching
contents, so that different types of learners can be addressed
in the best possible way [13,16,17]. Finally, the German Rectors’
Conference and the Council of Science and Humanities call for
the sustainable establishment of e-learning in teaching [18,19].
In doing so, they are following the efforts of the European Union,
which has been promoting the development of e-learning in
Europe for several years with various programmes. After the
conception of an electronic module on the issue of dental pain
(“Toothache Clinic”), which is freely available on the Internet,
we were interested in the following research questions:
1. How do the students rate the e-learning module
(“Toothache Clinic”)?
Abstract
This multivariate, prospective, monocentric, observational study evaluates the experimental
application of an interactive e-learning module on the topic of dental pain, which deals with the content
of interdisciplinary diagnostics and therapy of dental pain. The module (“Toothache Clinic”) was offered
to dentistry students during the fi rst, second and fourth clinical semesters. A total of n = 138 students
took part.
The questionnaire used in the study comprised 43 items (assigned to three domains) as well as
questions on academic progress, gender, information technology (IT) background and module evaluation.
The explorative factor analysis resulted in a reliability value (Cronbach’s Alpha) of 0.94. The results show
a good rating for the module of 2.09 ± 0.55 (1 = excellent to 6 = unsatisfactory) across all groups. 94.17%
of the volunteers would recommend the module to their fellow students. With a rating of 1.96 ± 0.51 (1
= excellent to 6 = unsatisfactory), women rated the module signifi cantly better than men who rated it
2.27± 0.67 (p = 0.016). There were no signifi cant differences in the ratings of the module between the
three semesters. Furthermore, the results show no signifi cant correlation between module assessment
and prior information concerning technology education. In summary, it can be said that the students
rated the e-learning module (“Toothache Clinic”) positively, regardless of their IT (information technology)
knowledge and academic progress. Keywords: pain medicine, dental, e-learning, gender, education
010
Citation: Keppel Hesselink JM, Kopsky DJ (2018) Neuropathic pain due to chronic idiopathic axonal neuropathy: fast pain reduction after topical phenytoin cream
application. Open J Pain Med 2(1): 009-014. DOI: http://doi.org/10.17352/ojpm.000009
2. Do students from different semesters evaluate the
e-learning module (“Toothache Clinic”) differently?
3. Does students´ gender (male or female) have an
infl uence on the assessment of the e-learning module
(“Toothache Clinic”)?
4. Does the students’ previous IT (information technology)
knowledge correlate with the evaluation of the
e-learning module (“Toothache Clinic”)?
Materials and methods
The e-learning module
The e-learning module (“Toothache Clinic”) was created
with an open source authoring tool called “Webkit Freiburg”,
licensed under “Creative Commons”, which is based on the
“Adobe Flash” technology [20]. It consists of a total of n = 83
pages, whose contents can be edited interactively using various
functions (tips, feedback, dropdown, radio button, checkbox,
free input, magnifying glass, image sequence, drag and drop).
Multimedia elements such as anamnesis sheets, fi ndings
sheets, extra- and intraoral photographs, X-ray images,
videos, animations, concept maps) optimize the presentation
of the individual didactic contents. A total of fi ve patient
cases from different areas of dentistry (case 1: conservative
dentistry, case 2: prosthodontics, case 3: periodontology, case
4: oral surgery and case 5: orthodontics) are integrated, all of
which have a common characteristic, namely the presence of
acute dental pain. The respective learning objectives (n = 30
in total) are based on the specifi cations of the “Swiss learning
objectives catalogue for dentists” from 2008 [21] and the ADEE
(Association of Dental Education in Europe) specifi cations
[22, 23]. The patients were recruited from the patient courses
of the University Dental Clinic. Their consent to the use of
their fi ndings and illustrations was obtained previously. The
page order is fi xed, but pages can be skipped via the menu,
and the user can also jump back to previous pages. The given
sequence begins after the initial examination, a case vignette
and the display of the case-specifi c learning objectives with
the general anamnesis (step 1), followed by the pain anamnesis
(step 2) and the clinical fi ndings (step 3). This is followed by
diagnosis (step 4) and therapy (step 5). The case ends with the
page “Behandlungsende” (end of treatment) (step 6) and the
output test.
The questionnaire
The questionnaire designed according to the “Ulmer
Qualitätskriterien für Lernprogramme in der Medizin”
(Ulm quality criteria for learning programmes in medicine)
was divided into several sections [5,9,24]. After the “Code
zum Wiedererkennen” (code for recognition), “Allgemeine
Angaben” (general information) was queried: age, gender,
number of semesters, Abitur grade, previous technical
knowledge, vocational training. In the section “Spezielle
Fragen” (special questions) an assessment of the entire module
and information on the processing time as well as the time
of day were requested. The individual cases were assessed in
sections four to eight. Further sections included “Bedienbarkeit
und Technik” (handling and technical aspects) with 14 items,
“Inhalt und Funktionsumfang” (content and functional
range) with 8 items, as well as “Didaktik und Eignung für die
Ausbildung” (didactics and educational value) with 21 items.
The evaluation of the items was assigned by a Likert scale from
0 (“does not apply at all”) to 3 (“applies completely”). Free
text comments were also possible.
Blended learning
The “Toothache Clinic” is part of the integrated Frankfurt
dental medicine e-learning strategy “FranZI”. Integrated
into the curriculum, the e-learning contents are provided in
class. Embedded in a blended learning scenario, a mixture of
e-learning and classroom teaching arises. For the application
of e-learning, students have four computer workstations with
Internet access in the library of the dental clinic as well as four
further computer workstations with Internet access in the so-
called “LernLab” at their disposal. The students of the fi rst
clinical semester also have the possibility to use the Internet
at their treatment units in the course room (n = 24 computer
workstations) of the phantom course for conservative dentistry.
Further opportunities for online and offl ine computer work
are provided by the main medical library on the campus of the
University Hospital as well as the WLAN network available in
the dental clinic, provided that a portable computer is available.
Study period and setting
For this study the data of three parallel semesters (fi rst,
second and fourth clinical semester) during the winter semester
2010/11 were collected (Table 1). The ethics application of
the monocentric and self-initiated study was assigned the
reference number 154/11 by the ethics commission of the
Faculty of Medicine of the Goethe University Frankfurt am
Main.
Preparatory measures by those learning
At the beginning of the 154-day evaluation phase, the
students received a 15-minute introduction to the use of the
module with the following contents: Announcement of the URL
of the e-learning module, assurance of complete anonymity
of the incoming and outgoing tests, reference to the concept
maps, reference to any increased loading times, indication of
an e-mail address for technical support, explanation and issue
of the evaluation forms and user names, announcement of
the deadline, enquiry of the e-mail addresses of the semester
speakers, answers to any technical or procedural questions the
students may have.
Table 1: Distribution of questionnaires to students in the different semesters,
including average age and gender (clin. = clinical).
Semester Number Men Women Age
1st clin. sem. 35 8 27 25.5
2nd clin. sem. 60 22 38 25.8
4th clin. sem. 43 15 28 26.2
Total 138 45 93 25.8
011
Citation: Keppel Hesselink JM, Kopsky DJ (2018) Neuropathic pain due to chronic idiopathic axonal neuropathy: fast pain reduction after topical phenytoin cream
application. Open J Pain Med 2(1): 009-014. DOI: http://doi.org/10.17352/ojpm.000009
Preparatory measures by those teaching
The teaching staff of the department (conservative
dentistry) was informed about the application of the elearning
module in blended learning scenario. In addition, they were
given access data to enable them to use the module.
Statistics
For the statistical analysis of the results, the Wilcoxon test
with a signifi cance level of p ≤ 0.05 was applied. The Wilcoxon
test was performed using the statistical analysis package
“WinStat for Excel”, version 2003.1.
Results
After returning the evaluation forms, a population of n =
104 students remained (Table 2).
Response rate
The response rate for all semesters was 74%. The fi rst
clinical semester had a response rate of 94%, the second
clinical semester of 75% and the fourth of 58%. The average
drop-out rate was 25%.
Exploratory factor analysis
The explorative factor analysis (main axis factor analysis)
showed that there are three factors. This is in line with the
theoretical construct according to which the evaluation sheet
was drawn up. The reliability values of the three factors are
shown in table 3. The entire questionnaire received a reliability
value of 0.94.
Non-group-specifi c results
All test person groups gave the fi ve cases an average
school grade (1 = excellent to 6 = unsatisfactory) of 2.09 ±
0.55 (Table 4). On average, the fi rst case (paediatric dentistry)
was rated signifi cantly better with 2.04 (± 0.57) than case two
(prosthetics) with 2.18 (± 0.68) and case fi ve (orthodontics)
with 2.29 (± 0.80).
81% of the subjects found the e-learning module to be
helpful in exam preparation. 93% rated the module as helpful
in preparing for clinical courses. 84% found it helpful as
emergency service preparation. 94% of those surveyed would
recommend it to their fellow students.
Gender-specifi c results
Men rate their own previous IT knowledge signifi cantly
better (2.14 ± 0.87) than women (2.52 ± 0.76) at a pvalue of
0.038. The other specifi c questions and the three factors were
not answered signifi cantly differently. The fi ve cases were
rated signifi cantly better overall by women (school grade 1.96)
while all cases averaged 2.27 (p = 0.016) for men (Table 5). In
the individual assessment, the fi rst, third and fi fth cases were
rated signifi cantly better by women than cases two and four.
Semester-specifi c results
There are no signifi cant semester-specifi c differences in
the overall and individual assessment of the fi ve cases, nor
in the previous IT knowledge, nor in the three factors and all
other specifi c questions.
Correlation of previous IT knowledge
The previous IT knowledge does not correlate in any way
with the evaluation of the module.
Discussion
The interdisciplinary concept and the division of the
module into fi ve cases are mostly rated positively in the free
text comments. One working group recommends the use of
e-learning modules as an optimal instrument for conveying
interdisciplinary content [11]. This was confi rmed by the
Table 2: Distribution of study population by semester, age and gender (clin. =
clinical).
Semester Number Men Women Age
1st clin. sem. 33 7 26 25.5
2nd clin. sem. 45 13 32 25.7
4th clin. sem. 25 8 17 26.0
Total 104 28 75 25.7
Table 3: The examined factors with the corresponding questionnaire items, the
calculated Cronbach Alpha (CA) values and the average evaluation including the
standard deviation on a Likert scale from 0 ("does not apply at all") to 3 ("applies
completely").
Factor Items CA Evaluation
1. Didactics and educational value 10.4, 11.1-11.21 0.93 2.03 ± 0.45
2. Handling and technical aspects 9.1-9.14 0.89 2.13 ± 0.47
3. Content and functional range 10.1-10.3, 10.5-10.8 0.82 1.83 ± 0.50
Table 4: Evaluation of the fi ve cases of the pain-e-learning module “Tootache
Clinic” on a scale from 1 = excellent to 6 = unsatisfactory and the corresponding
signifi cances (SD = standard deviation, Min = Minimum, Max = Maximum).
Case 1 (conservative
dentistry) 2.04 2.00 0.57 1.00 4.00 case 2 (0.03), case 5
(0.04)
Case 2 (prosthodontics) 2.18 2.00 0.68 1.00 4.00 case 1 (0.03)
Case 3 (periodontology) 2.13 2.00 0.70 1.00 4.00 no signifi cance
Case 4 (oral surgery) 2.05 2.00 0.75 1.00 4.00 case 5 (0.02)
Case 5 (orthodontics) 2.29 2.00 0.80 1.00 4.00 case 1 (0.04), case 4
(0.02)
Total 2.09 2.00 0.55 1.00 4.00
Table 5: Evaluation of the fi ve cases of the pain-e-learning module “Tootache
Clinic” on a scale from 1 = excellent to 6 = unsatisfactory and the corresponding
signifi cances subdivided according to the gender of the subjects.
pain-e-learning case Men Women Signifi cant to
Case 1 (conservative dentistry) 2.27 ± 0.67 1.96 ± 0.51 Yes (p = 0.024)
Case 2 (prosthodontics) 2.39 ± 0.66 2.10 ± 0.67 No
Case 3 (periodontology) 2.50 ± 0.71 1.98 ± 0.65 Yes (p = 0.003)
Case 4 (oral surgery) 2.25 ± 0.79 1.95 ± 0.72 No
Case 5 (orthodontics) 2.75 ± 0.76 2.12 ± 0.74 Yes (p = 0.004)
Total 2.27 ± 0.67 1.96 ± 0.51 No (p = 0.016)
012
Citation: Keppel Hesselink JM, Kopsky DJ (2018) Neuropathic pain due to chronic idiopathic axonal neuropathy: fast pain reduction after topical phenytoin cream
application. Open J Pain Med 2(1): 009-014. DOI: http://doi.org/10.17352/ojpm.000009
good acceptance of the “Zahnschmerzambulanz: Advanced”
(toothache clinic: advanced).
On average, the three factors were rated slightly better by
the women, but not signifi cantly so. One striking deviation
concerns items 10.4 (“Die medizinischen Lernziele sind
deutlich ausgewiesen” / “The medical learning objectives are
clearly stated”) and 11.6 (“Der Einsatz multimedialer Elemente
fördert das Verständnis vom angebotenen Lerninhalt” / “The
use of multimedia elements promotes understanding of the
learning content offered”), which were rated signifi cantly
better by women than by men. This could indicate that women
have a greater “natural” motivation to e-learning in virtual
patient cases, which could be explained by differences in
learning behaviour between the genders [25]. Men usually have
better spatial perception than women. The latter therefore fi nd
e-learning an appropriate learning medium, as it visualises
content in different ways and thus supports the learning
process [13, 16, 17]. The good female evaluation shows that
this seems to have been successful in this module. However,
it should also be questioned how e-learning modules can also
be optimised to meet male needs. For example, this could be
achieved by clearly demonstrating the practical benefi ts that
elearning can have for them [11].
A questionnaire was used for the evaluation, which was
examined with regard to the criteria objectivity, validity
and reliability, standardised in structure and content, and is
thus comparable between different universities. It is based
on the “Ulmer Qualitätskriterienkatalog für medizinische
Lernprogramme” (Ulm quality criteria for learning
programmes in medicine) [24]. The reliability of such a
questionnaire is measured by means of the Cronbach Alpha
[26]. At over 0.9 for the entire questionnaire, the reliability
of the used questionnaire calculated by Cronbach’s Alpha
– as a prerequisite for its validity – is excellent. It can thus
be regarded as very reliable. Other studies also evaluate their
questionnaires using Cronbach’s Alpha, which makes the
reliability directly comparable as required by a working group
[1,24].
The results confi rm that students feel more confi dent in
their abilities through virtual patient simulations in the clinical
part of the study and therefore support the use of such modules
[12]. The factors “didactics and educational value” as well as
“ handling and technical aspects” were assessed between
2.03 and 2.13 on average. The students rate the module as
most suitable for self-study. As indications for the further
use of this module group lessons or use in class are rated as
strongly below average. This could be based on the fear of
students that this or similar modules would be saddled on top
of the previous curriculum, which already has an enormous
workload. Students may also see no meaningful indication or
method of how the module could be integrated into classroom
teaching and therefore reject these items. This is where one
working group calls for more detailed studies on how virtual
patient cases could be better integrated into and adapted to the
curriculum [10].
Apart from the different levels of previous computer
knowledge, which have no infl uence on learning success in
e-learning, men and women approached the module with
the same prerequisites. The poorer IT skills of the women
in the self-assessment correspond to the fi ndings of other
studies. However, they have no infl uence on the evaluation of
e-learning content [27].
Women do not consider the module more recommendable
than their fellow male students. However, they tend to
recommend it more frequently for preparation for clinical
courses and examinations. This non-signifi cant positive
evaluation is even more pronounced in the grading of the
fi ve cases, which on average is signifi cantly better than the
evaluation by men. The overall better rating of cases by women
could be related to the fact that interactive patient simulations
are closer to the needs of the explorative-developing learning
method of women described by Gunn than to the practical-
instrumentalizing learning behaviour of men [27]. This is
also supported by the fact that women generally learn more
successfully with e-learning courses than men. According
to one study, women tend to be more inclined towards self-
directed learning behaviour, which fi ts very well with the
voluntary and interest-based conception of this module [17].
The generally positively evaluated usability of the module
seems to benefi t women in particular. Furthermore, women
seem to prefer interactive content more than men [28].
The homogeneous evaluation of the module by all three
semesters involved, as well as the lack of correlation with their
scolar (Abitur) and university (Physikum) grades, shows that
the prior knowledge of the study participants had no infl uence
on the evaluation of the module, because achievements in
medical studies normally correlate with these grades [29]. This
might be connected to the fact that all information necessary
for the solution of the cases was kept in the module itself. The
prior level of knowledge that was absolutely necessary for
processing was therefore – as intended – low. However, it also
indicates that not only the contents offered were evaluated,
which would probably have led to greater fl uctuations between
the semesters and examination marks if the conditions had
varied, but also didactics, conception and implementation.
The positive result of the evaluation, independent of previous
knowledge, thus underlines the good validity of this study.
Different levels of experience in dealing with a computer
had no signifi cant effect on the assessment of the modules.
In the future, this question is likely to become more and
more of a secondary concern, since IT competence correlates
signifi cantly and positively with the age group of the students,
i.e. the younger students bring with them probably greater
computer knowledge and skills. The development team aimed
for a processing time of 30 to 45 minutes per case, based on the
time for a classic school lesson. The evaluation showed that this
goal was achieved with a median of 30 minutes. The duration
of use of e-learning modules is rarely stated in literature but
is usually between 30 and 60 minutes [28,30,31]. Nevertheless,
in the free text comments students requested that in future
modules the contents per case should be reduced, possibly in
favour of an increase in the number of individual cases.
013
Citation: Keppel Hesselink JM, Kopsky DJ (2018) Neuropathic pain due to chronic idiopathic axonal neuropathy: fast pain reduction after topical phenytoin cream
application. Open J Pain Med 2(1): 009-014. DOI: http://doi.org/10.17352/ojpm.000009
Internal validity (Maturation and selection / recruitment
of test persons
During the twelve-week evaluation phase, various exams
in the subjects of orthodontics, oral surgery, periodontology
and prosthodontics were included in the three participating
semesters, which were very important for the course of studies.
Depending on the time in which the module was worked on,
these could have resulted in a different prior educational
background.
As this study was conducted within the framework of the
Department of conservative dentistry, only students of the
three semesters who also participate in courses at this polyclinic
were included. Functionality, accessibility and framework
dates were explained and demonstrated to each of the three
semesters at the beginning of the study and any questions were
answered. Students who did not take part in this event or were
inattentive would have had different prerequisites. In order
to counteract this effect, all information provided during the
event was distributed several times by email to all students of
the three semesters. Study participants could not be obliged to
submit the evaluation forms. Therefore, it cannot be ruled out
that a higher proportion of those who are fundamentally more
positive about e-learning will have submitted questionnaires,
which would have lead to a falsifi cation of the results in favour
of a more positive outcome. This was to be counteracted by
a preferably low drop-out rate made possible through direct
personal contact with the students when collecting the
evaluation forms.
The multicentered implementation and evaluation of the
module not only through written questionnaires but also
through the storage of all user activities using a database
would also be very desirable for the future. One working group
found strong discrepancies in 10-15% of the evaluation forms
submitted for an e-learning module compared to the actual
user behaviour recorded in databases [28].
Conclusion
In summary, it can be concluded that dental students rated
the pain-e-learning module “Toothache Clinic” positively,
regardless of their gender, previous IT knowledge and academic
progress.
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