Dental Case, a Brazilian Serious Game for Supporting Decision-making in the Dental Clinic: A Case Study

Abstract

Background: Games are intrinsic to society and are used to represent a wide variety of human activities. Contemporary society has been digitalized, and the habit of playing games has naturally migrated to the digital environment. The use of digital games in education, where they are known as serious games, has given rise to the introduction of new educational approaches for dental students and dentists, which complement traditional approaches. A brief conceptual outline of games can help broaden our understanding thereof in social and educational contexts. Objective: To report the designing and development of a serious game for decision-making in clinical case management in the field of dentistry, for use as a complementary teaching tool. Method: The method used was a case study to describe the development of the content and narrative of a Brazilian serious game for decision-making in the dental clinic, called Dental Case. A player in Dental Case takes on the role of a dentist during a consultation, with the mission of completing the steps of anamnesis, clinical examination, complementary examination, diagnosis, and treatment. The clinical cases presented in the game were designed to resemble real-life decision-making situations in the dental clinic of a primary healthcare setting. The content developed was reviewed and validated by specialists, from both a technical and pedagogical point of view, and then included in the game software by an information technology (IT) team. Results: Dental Case was developed from a set of clinical cases. The game targets dental professionals and students, and its goal is to lend support to the teaching of decision-making in the different stages of clinical care. The game is freely available on the web, and on the Play Store and Apple Store mobile application platforms. Conclusions: The resources made available by Dental Case constitute a new complementary pedagogical approach, and a tool for the application of educational technologies in dentistry, which can contribute to expanding the scale and reach of educational activities. Future research is warranted to investigate the effectiveness of Dental Case in promoting learning and should include an evaluation of its performance by its users.

Full text

CASE STUDY
European Journal of Dental and Oral Health
www.ejdent.org
DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
Vol 4 | Issue 5 | October 2023
10
Dental Case, a Brazilian Serious Game for Supporting
Decision-making in the Dental Clinic: A Case Study
Camila Huanca, Deise Garrido, Mario Teixeira, Alana Oliveira, Paola Trindade,
Ana Emilia Figueiredo and Ana Estela Haddad
ABSTRACT
Background: Games are intrinsic to society and are used to represent a wide
variety of human activities. Contemporary society has been digitalized, and
the habit of playing games has naturally migrated to the digital environment.
The use of digital games in education, where they are known as serious
games, has given rise to the introduction of new educational approaches for
dental students and dentists, which complement traditional approaches. A
brief conceptual outline of games can help broaden our understanding
thereof in social and educational contexts.
Objective: To report the designing and development of a serious game for
decision-making in clinical case management in the field of dentistry, for use
as a complementary teaching tool.
Method: The method used was a case study to describe the development of
the content and narrative of a Brazilian serious game for decision-making in
the dental clinic, called Dental Case. A player in Dental Case takes on the
role of a dentist during a consultation, with the mission of completing the
steps of anamnesis, clinical examination, complementary examination,
diagnosis, and treatment. The clinical cases presented in the game were
designed to resemble real-life decision-making situations in the dental clinic
of a primary healthcare setting. The content developed was reviewed and
validated by specialists, from both a technical and pedagogical point of view,
and then included in the game software by an information technology (IT)
team.
Results: Dental Case was developed from a set of clinical cases. The game
targets dental professionals and students, and its goal is to lend support to
the teaching of decision-making in the different stages of clinical care. The
game is freely available on the web, and on the Play Store and Apple Store
mobile application platforms.
Conclusions: The resources made available by Dental Case constitute a new
complementary pedagogical approach, and a tool for the application of
educational technologies in dentistry, which can contribute to expanding the
scale and reach of educational activities. Future research is warranted to
investigate the effectiveness of Dental Case in promoting learning and should
include an evaluation of its performance by its users.
Keywords: clinical decision-making, dentistry, educational technology,
permanent education, serious game, video game.
Published Online: October 11, 2023
ISSN: 2684-4443
DOI: 10.24018/ejdent.2023.4.5.289
C. Huanca*
Telehealth Center, School of Dentistry,
University of São Paulo, Brazil.
(e-mail: camila.huanca@usp.br)
D. Garrido
Santo Amaro University, São Paulo, SP,
Brazil; Telehealth center, University of
São Paulo, Brazil.
(e-mail: deisegarrido@usp.br)
M. Teixeira
Federal University of Maranhão, Brazil.
Open University of the Unified Health
System and Federal University of
Maranhão, Brazil
(e-mail: Mario.meireles@ufma.br)
A. Oliveira
Federal University of Maranhão, Brazil.
Open University of the Unified Health
System and Federal University of
Maranhão, Brazil
(e-mail: alana.oliveira@ufma.br)
P. Trindade
Federal University of Maranhão, Brazil.
Open University of the Unified Health
System and Federal University of
Maranhão, Brazil
(e-mail: paola.garcia@ufma.br)
A. E. Figueiredo
Federal University of Maranhão, Brazil.
Open University of the Unified Health
System and Federal University of
Maranhão, Brazil
(e-mail: ana.figueiredo@ufma.br)
A. E. Haddad
School of Dentistry, University of São
Paulo, Brazil.
(e-mail: aehaddad@usp.br)
*Corresponding Author
I. INTRODUCTION
Storytelling and playing are closely intertwined actions.
Their history developed with that of humanity, and they
contribute to structuring our culture. Games allow us to
symbolically enact activities that give meaning to our lives,
such as work and education [1], [2]. Games can be found in
several fields of knowledge, and have long been used to train
people, and as a way of developing new perceptions [3]. They
provide safe training in simulated environments, for typical
activities conducted in real life. As such, they constitute a trial
for living life [1], help players develop a sense of self-
efficacy, and provide them with the confidence required to
exercise newly acquired skills [4].
A. Serious Games for Clinical Decision Making
Clinical decision-making is the process by which a health
professional solves a problem using his/her clinical reasoning
comprised of practical and theoretical knowledge, skills, and
attitudes and all the resources available to overcome
uncertainties [5]. Correct diagnosis and treatment depend on
obtaining complete, reliable data from the patient through a
global assessment, which includes history-taking, clinical
examination, radiographs, and laboratory tests [6]. Clinical
decision-making is an important part of medical education,

CASE STUDY
European Journal of Dental and Oral Health
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DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
Vol 4 | Issue 5 | October 2023
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and has been taught using a variety of methods, including
computational strategies, cognitive training, and even
sociology [7]-[9].
The literature shows that education and training improve
clinical-reasoning skills, thus improving diagnostic
performance and reducing operational errors. Several
cognitive strategies have been proposed to provide better
diagnostic decisions. One such strategy is to increase the
student's experience by using simulations [10], [11]. Training
for biliary tract surgery [12], the emergency care of patients
with tachyarrhythmias [13], the home care of patients with
chronic obstructive pulmonary disease [14], and trauma
triage in an emergency ward [8], [15] are some examples of
serious-game content that simulate clinical decision-making.
B. Serious Games in Dentistry
Game technology provides a new and different approach to
education at the undergraduate, graduate [16], and continuing
professional development [17] levels. However, there are few
reports on the use of serious games as auxiliary resources for
dental learning [16], [18]–[21]. It is known that the use of
serious games is a valid option for dental education; however,
serious games remain underused and poorly researched in this
area [18]. Researchers have described games only as
complementary tools for dental teaching, and have reported
deadlocks in their development [16]. In addition, there are
few serious games for decision-making in the field of
dentistry [21], [22]. Therefore, there is a gap in the available
knowledge provided in the literature regarding the use of
serious games for this field.
Brazil is the country with the highest absolute number of
dentistry courses worldwide, and one of the countries with the
highest number of dentists [23]. Thus, the Open University of
the Unified Health System and Federal University of
Maranhão (UNA-SUS/UFMA), the Graduate Program in
Design of the Federal University of Paraná, and the
Telehealth Center of the University of São Paulo School of
Dentistry, pooled together to develop Dental Case, an
innovative project aimed at meeting the educational and
training needs of clinical professionals, by using information
and communication technologies to expand the scale and
reach of educational activities [17]. Dental Case is a serious
game created to support the decision-making process in the
dental clinic. The game was developed based on the
understanding that quality education is achieved not only
with traditional approaches, but also with pedagogical,
technological, design, and communication innovations,
among other interdisciplinarities. Thus, this study reports on
a project aimed at developing a decision-making serious
game, which introduces a gamified simulation of clinical
cases as an innovative method for the education and training
of dentists and dental students.
II. METHOD
A. The Dental Case Project and Its Development
The method used in this case study was descriptive
research into the development of the content and narrative of
the Dental Case game, and its interface with the pedagogical
and technological dimensions. The project was managed by
UNA-SUS/UFMA, and was developed based on the premise
adopted by this institution that educational resources should
be associated with design, pedagogy, and technology. An
interdisciplinary team of about twenty members cooperated
with the project and included game designers, managers,
pedagogues, instructional designers, information technology
(IT) professionals, dental professors from the disciplines of
pediatric dentistry, radiology, restorative dentistry,
biomaterials, and oral biology, as well as doctoral and post-
doctoral dental students experienced in clinical care, the latter
being responsible for the content and narrative of the game.
During the development of the Dental Case Project, a
series of workshops were held as part of the creative process,
in which the entire interdisciplinary team participated
actively in the formulation of its main concept, educational
content, learning objectives, and branched stages.
Dental students and dentists are the target audience of the
Dental Case serious game, which may include people used to
playing digital games, as well as people with little or no
experience. Players in Dental Case do not interact with other
players, i.e. their experience is individual.
The purpose of Dental Case is to test the player's clinical
reasoning during dental care, with the ultimate goal of
reaching the best possible outcome in terms of the patient's
health. The player's knowledge is evaluated during the course
of the consultation (comprising the steps of anamnesis,
clinical examination, complementary examination, diagnosis,
treatment, and patient communication) in relation to his/her
ability to make decisions in each step. The player’s ability to
analyze test results is scored positively or negatively,
depending on whether the game's algorithm judges his/her
choices as appropriate or inappropriate, respectively. The
player's choices are also scored in relation to humanized care
and economic considerations related to the costs incurred by
the Unified Health System (SUS). Pedagogical feedback and
the corresponding bibliographic references that support it are
presented at the end of the game to further contribute to the
player's learning experience.
B. Content of Dental Case
Subsequently, this instrument was improved by the IT
team, and received the contributions of the pedagogical and
content writer teams, ultimately resulting in a clinical-case
authoring tool to be used by content writers to speed up the
clinical case construction process [24]. The aims of this tool
are (1) to guide content writers to structure the content in the
steps of anamnesis, clinical examination, complementary
examination, diagnosis, treatment, and patient
communication; and (2) to set the limits of the narratives
included in the game to a pre-defined number of characters.
The content of each stage is displayed on the screen of the
game.
The content writer team received the input of pedagogues
and technical reviewers specializing in the subject matter
being addressed in each case, so as to validate and ensure the
quality of the content developed for Dental Case. The content
included by the content writers using the authoring tool
underwent a technical review that determined whether the
clinical cases and features of the cases described at each stage
were consistent with the best available scientific evidence.
This technical review was performed by two dental
professors with more than twenty years of experience. The

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European Journal of Dental and Oral Health
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DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
Vol 4 | Issue 5 | October 2023
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content of each case was then either approved or disapproved.
If approved, the content would move on to the next step: the
pedagogical review. If disapproved, the required adjustments
were pointed out by the technical reviewers and forwarded to
the content writer to make the necessary corrections. Once the
adjustments were completed, the content was sent back to
undergo a new technical review, and then to a final
pedagogical review.
The IT team then used the approved content to produce the
software for the game, comprising the following steps:
exporting the content of the cases from the content authoring
tool, coding each case in a specific programming language,
and incorporating images, audios, and other multimedia
resources into the game. After these steps were completed,
the game underwent a final phase of testing and internal
validation. At this point, a team was formed to assess the
quality of the game, and was also invited to play Dental Case
freely. The notes made by the validators were then used to
make adjustments and improvements to the executable
version of the game to be made available at application stores
[25].
C. Dental Case Narrative
Overall, the game uses the traditional narrative structure of
cinema [26], with specific subdivisions created by the game
design team and described below:
Beginning, Act 1 (prologue): the game presents the setting
where the narrative takes place between dentist and patient.
Middle, Act 2 (conflict): the patient states his/her
complaint, and Act 3 (rising action): the dentist begins the
anamnesis and clinical examination; at this stage, unforeseen
occurrences or interferences in the dynamics of the game may
take place to make it more exciting.
End, Act 4 (falling action): the dentist selects the
complementary tests and gives the final diagnosis, and Act 5
(resolution): the chosen treatment or conduct is indicated, and
the player receives pedagogical feedback regarding his/her
choices.
The narrative of each clinical case was developed to
stimulate player involvement, so that he/she remains focused
on the objective of the game. To this end, and guided by the
protocol specifications, the content team detailed several
aspects of the central narrative of the patient's complaint.
Accordingly, the dental chair stage received virtual patients
whose characteristics were consistent with the clinical case
detailed by the content writer, and the illustrators were able
to capture the patient's profile and translate it into realistic
illustrations, containing relevant data for decision-making.
Some of the physical aspects specified were age group,
ethnicity, color, gender, and body mass index (BMI), as well
as specifics related to occasional deficiencies (hearing,
cognitive, motor and/or visual) and their severity. Each
patient was personified, by including a medical record
containing his/her health history, family health history, and
data regarding age, sex, BMI, number of pregnancies, type of
delivery, gender expression, marital status, level of education,
work activity, family income, and area of residence. The
content writer then created a tree of possibilities based on the
previously conceived personification.
D. Structuring a Tree of Possibilities
The main challenge for the player is to meet the patient's
demands and solve his/her case. In order to accomplish this
task, the player makes choices during the care stages. The
choices available in the game are part of a tree of possibilities
included in the protocol.
The tree of possibilities provides three types of alternatives
for decision making: appropriate, plausible, and inappropriate
alternatives. The more correct the player's choices, the better
his/her score. The different types of alternatives presented in
the game make it more challenging, since they render
decision-making more difficult for the player. Furthermore,
the game may offer more than one option for each type of
alternative (Fig. 1).
Fig. 1. Tree of possibilities.

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DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
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Unusual situations that might occur in consultations at a
basic health unit were also included in the game. Thus, the
narrator included situations causing the consultation to be
interrupted, such as the ringing of a cell phone, external
noises, a power outage, or the lack of patient cooperation, as
an additional challenge to test the player's decision-making
skills. The tact required of the dentist when asking questions
and communicating the diagnosis and treatment to the patient
is also contemplated in the game narrative formulated by the
content writer; accordingly, humanized care features are
included in the alternatives available to the player.
After managing the patient's clinical case, the player
receives pedagogical feedback containing didactic
contributions to the development of his/her knowledge with
respect to each stage of the care-giving process.
III. RESULT
The serious game presented in this report is a gamified
simulation of clinical cases. The content writers developed
the script, prepared the clinical cases, selected and included
the results of the radiographic and other relevant
complementary examinations (with information in the form
of texts and images), and built the pedagogical feedback
reports. The game's narrative takes place in a basic unit of the
SUS, and the player selects an avatar among six existing
configurations of a dentist about to start his/her clinical
workday. The game unfolds from the perspective of the
avatar-dentist. The dentist chooses among the many patients
available for treatment, each one presenting with complaints
and symptoms that are then investigated by the professional,
using the most appropriate selection of history-taking
questions, clinical tests, and complementary tests to diagnose
and treat correctly. The cases are similar to real-life dental
situations commonly found in the context of primary
healthcare, and were designed with the goal of contributing
to the training of SUS professionals.
Dental Case has recently been launched in its beta version
and was programmed using the Unity game engine (Unity
Technologies). The game took approximately two years to
develop from its conception to the current version but is still
under development to incorporate new features. Content
writers continue to feed the authoring tool with new clinical
cases to be added to the 20 cases included so far. The IT team
is playing and testing the cases to detect and fix any problems
and has already produced a Dental Case version using web
technologies, namely the React JS development framework
[27]. This version allows the game to be ported more easily
to a variety of browsers and mobile devices based on the
Android and iOS platforms.
The authoring tool created by the IT team to allow the
development of a narrative, avatars, and an image database of
characters, environments, and equipment has systematized
the work of the content writer, pedagogue, and technical
reviewer teams, as documented in the Dental Case
development meeting reports. In addition to this authoring
tool, other products related to the development of the game
were created and registered at the National Institute of
Industrial Property (INPI) under the following names and
registration numbers: SAITE Image Pack Dental-Case
Scenarios / BR512019002777-9, SAITE Image Pack Dental-
Case Characters / BR512019002778-7, SAITE Dental Cases
(iOS) / BR512019002775-2, and SAITE Dental Cases
(Android) / BR512019002773.
It is an open-access game, and freely available on the web
and at Google Play and Apple Store for mobile devices, in
Brazilian Portuguese, English and Spanish, in that the last two
were automatically translated by the Google Translator API.
Player interaction with Dental Case can be made by mouse
on the web, or by touching the screen of a mobile device.
Some illustrations of the game are shown below (Figs. 2–4,
representing screenshots from Dental Case).
Fig. 2. Choosing a clinical case.
Fig. 3. Choosing an avatar.
Fig. 4. Dentist receiving the patient.
IV. DISCUSSION
Digital technologies have caused a permanent change in
both society and the individual toward the way people live,
work, and entertain themselves. According to McLuhan,
games translate experiences and give new forms to already
known situations [3].
The present case report describes not only a project that
involves the building up of interdisciplinary knowledge but
also the production of a serious game for decision-making in
the dental clinic, both of which are innovative. After
conducting a review of the related literature, a few serious
games devised for this purpose were found in the field of
dentistry. The literature search found only one serious game

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European Journal of Dental and Oral Health
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DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
Vol 4 | Issue 5 | October 2023
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about tooth caries and tooth pulpitis [21], and another serious
game developed about dental public health education [22].
Therefore, the serious game described herein can be
presumed to be one of the few games for decision-making
targeting the dental public.
Dental Case is a serious game designed to contribute
interactively to the honing of the decision-making skills of
dental students and dentists, providing them with a significant
learning experience through the simulated care of patients in
several different situations occurring in a primary healthcare
setting. The goal was to present players with several dental
clinical cases that would enable them to enhance their
experience, and encourage them to identify gaps in their
knowledge in order to develop their data collection skills, to
name just one aspect. The ongoing pandemic at the time this
report was published caused many students to miss many
hours of clinical training, as a result of the restrictions
imposed on in-person care [28]–[30]. Although Dental Case
cannot replace this practice entirely, the game constitutes a
complementary mode of training for the management of
clinical cases that professionals and students were kept from
managing during the pandemic. By enabling the practice of
clinical decision-making in a digital, controlled, and secure
environment, the game provides clinical training without
involving any risk to the health of real patients, as reported
by Graafland et al. in a systematic review of serious games
[4].
Research conducted with serious games as a means of
training or acquiring experiences to improve decision-making
skills have shown that these simulations are effective in
promoting positive changes in the participants' performance
[8], [15]. The main findings of one such study confirm the
validity of using serious game technology to study physicians'
decision making, considering that the pattern of decisions
made while playing seemed consistent with the patterns
found in real-life practice [31]. In addition, players have
reported a sense of responsibility in decision-making [13],
have considered cases clinically relevant [14], [32], and have
perceived the fun involved in the act of playing [12], [13]
Developing a game to better qualify students and dentists
is in line with the literature that shows that serious games
have been widely used in the field of medical education,
owing to the positive results obtained by medical students
toward learning and participation [13], [33]. Accordingly,
researchers have encouraged the use of this type of
application [16], [20].
The making of Dental Case was only possible due to the
robust contribution of the different teams involved. Its
construction and development were complex tasks, which
required the simultaneous and cross action of an
interdisciplinary team, as reported by Novak with respect to
the development of commercial games [26]. The goal of the
Dental Case project is to promote learning through the game
process, which includes the posing of challenges,
performance assessment, and the possibility of repeating
tasks, in addition to providing pedagogical feedback in the
form of commentaries—and accompanying bibliographic
reference—to the alternatives chosen by the player during the
game. By presenting a range of appropriate, plausible, and
inappropriate alternatives, the game allows the player's score
to rise or fall as his/her choices switch between more or less
appropriate. The player can monitor his/her performance
immediately, by observing his/her partial score displayed on
a bar on the screen pertaining to each stage of the care being
provided. This game mechanism contributes to expanding the
player's knowledge, and refining the accuracy of his/her
choices, as reported in the research conducted by Mohan et
al. [15].
Text The main concern of developers when designing
serious games is to maintain a balance between their two most
important components: content and entertainment [4], [5].
However, some researchers argue that content is the central
aspect of a serious game [34], whereas others argue that it is
entertainment, i.e., that education should be subordinated to
narrative [35]. This contradiction found in serious games is
known as the “edutainment paradox” [36], [37]. The present
case study on the Dental Case Project describes the concern
of the team of content writers in developing an educational
resource that is faithful to real-life dental situations, but that
does not sacrifice fun or engagement. This same
understanding guided Diehl et al. when developing a serious
game on insulin therapy focusing on continuing medical
education [38]. The concern of the Dental Case developers
was to engage the player through the game's narrative,
scoring system, and unexpected situations, elements also used
by Danilicheva et al. [37]. These elements create an enjoyable
experience, and increase the player's intrinsic motivation.
A compelling narrative also contributes positively to the
game, as reported by Mohan et al. [15]. However, the
restriction to the number of characters allowed by the clinical
case protocol of the game's authoring tool proved to be a
limitation to the accuracy of the game in reproducing real life,
since it sometimes entails constructing overly succinct
questions and answers. On the other hand, the authoring tool
allowed a significant reduction in the time needed to create
clinical cases. During the meetings, there were positive
reports about the perception by content writers of their
experience in developing clinical cases, as well as the
perception by technical and pedagogical reviewers about
theirs in evaluating the content before and after creation of
the authoring tool. The tool was classified as useful and
capable of streamlining the teams' work process.
Supporting elements of the content are no less necessary,
and are also present in Dental Case. They allow the player to
view the patient's records containing health history, family
history, and demographic data. According to Johnsen et al.,
these data are important to help the player understand the
clinical case, and detect relevant clues to resolve the patient's
condition [14]. Some articles in the healthcare field report the
importance of designing games that are as realistic as
possible, and no less accurate in reproducing the studied
context, considering that the goal of using serious games is to
promote behavioral changes related to the continuing
education of a large number of professionals [39].
The significant learning experience sought by the
developers of Dental Case is in line with the literature that
highlights the importance of clinically relevant content
consistent with learning objectives and clinical practice [14],
[40]. This is because its goal is to increase the player's ability
to make appropriate decisions, care for the patient in a
humanized way, and make the most appropriate and relevant

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choices of complementary exams, for both the patient and
SUS, economically speaking.
According to Johnsen et al., playing is a way of stimulating
active learning [14]. Accordingly, the interdisciplinary team
of Dental Case defined the main concept of the game as an
encouragement to develop decision-making skills, and sought
to inspire players to apply, analyze, and synthesize
knowledge to make the most appropriate choices. In this
scenario, we agree with the statement by Pereira and
Walmsley that game technology and its application in the
field of dentistry have enormous potential [16].
Other positive features of the project are its open and free
access, and its availability both on the web and in the form of
an application for mobile devices. Therefore, the objectives
outlined by previous research of reaching a large number of
people interested in continuing education [5], [17] and
expanding the reach of educational resources using mobile
technology [17] are both enabled by Dental Case. This focus
on the goal of increasing scale and reach reflects an awareness
of the management team toward a particular feature of
Brazilian reality: the existence of a very large number of
current and future dentists in the country [23].
It is noteworthy that UFMA is one of the pioneering
institutions of the network of universities comprising the
UNA-SUS, a successful government strategy that promotes
the offering of free distance learning courses for continuing
education in healthcare [41]. By offering continuous
education, UNA-SUS/UFMA provides its students with a
virtual learning environment (VLE) that allows integration of
Dental Case into the existing set of courses offered on the
web.
The development of Dental Case for use with mobile
technology expands the reach of its educational resources to
SUS health professionals. The mobile format of the game
made available at the two largest application platforms is
meant to meet the demands of expanding mobile networks
and digital game usage, a trend also observed in the target
audience of Dental Case. Today the use of mobile devices is
commonly a part of people's daily lives, who remain in a state
of permanent connection. In fact, it is almost unimaginable
that a citizen of today's world would not rely on the
availability of a smartphone for the tasks of communicating,
obtaining information, and requesting services.
The mobile industry celebrated a milestone as the first
billion 5G connections were made by the end of 2022 [42]. In
Brazil, the digital population is 130 million, and 86.4 million
users count exclusively on mobile devices [43]. Digital games
are also present in Brazilian society, with 84% people using
various electronic devices to play games [44].
Thus, the relevance of mobile devices for education is
currently undeniable, a fact that has led to the incorporation
of the term mobile learning or m-learning in distance
education terminology, confirming the integration of mobile
technologies in education, and validating the use of
smartphones and tablets as learning channels. The ease of
having any sought-after knowledge readily available in the
palm of your hand at any time and place through these mobile
devices has expanded user autonomy and interest
exponentially, maximizing and invigorating the teaching-
learning process.
Some of the video games available are meant to be played
in groups; Dental Case, in contrast, was pedagogically
designed to be an individual game. This decision was made
during the game design process, when it was realized that
decision-making in clinical dental practice is mostly an
individual action. On the other hand, this means that the game
fails to offer what many digital games do: social interaction
within the virtual space shared by players from different parts
of the world [45]. As a result, in the jargon of the
entertainment games industry, Dental Case falls into the
category of "first-person shooter" games [46]. Evidently not
a shooting game, Dental Case is a first-person game in which
the “shooter” (dentist) has to make decisions (“shots”) that
lead him/her to success or failure in the game.
One limitation of the Dental Case development process is
that the content writer requires the assistance of the game-
design and IT teams to upload new clinical cases.
Nonetheless, a new version is already being developed to give
autonomy to content writers in carrying out this task. Another
limitation is related to the clinical case structure, in which
each phase of care has its own tree of possibilities. As a result,
the sequential and linear character of the player's progression
through the stages of the game reduces the possibilities of
game alternative randomization and combination.
Further investigation is warranted on the educational
effectiveness of the game in enhancing the decision-making
ability of dental students and dentists in the dental clinic, and
also on their experience and satisfaction with Dental Case.
The product should also be updated to include a
categorization by area of the clinical cases incorporated into
the software of the game.
V. CONCLUSION
The novel complementary pedagogical approaches in the
field of dentistry are needed. Dental Case developers are keen
to engage the player with appropriate content and narrative to
entertain and educate. The resources made available by
Dental Case require decision-making at different stages of the
dental care process, combined with robust pedagogical,
technological, and design support. They constitute a novel
tool in the armamentarium of dental educational technologies
and can contribute to expanding the scale and reach of
educational activities, both at the undergraduate level and in
the continuing education of dentists.
ACKNOWLEDGMENT
The authors are grateful to professors Luciane Fadel,
Daniella Munhoz, and Carla Spinillo for their support in
making this project a reality.
CONFLICT OF INTEREST
Authors declare that they do not have any conflict of
interest.

CASE STUDY
European Journal of Dental and Oral Health
www.ejdent.org
DOI: http://dx.doi.org/10.24018/ejdent.2023.4.5.289
Vol 4 | Issue 5 | October 2023
16
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