E-learning and Blended Learning in Orthodontic Education

E-learning

E-learning is the use of ICTs to enhance learning, knowledge, and performance. E-learning refers to the educational system, in which faculty and students are separated by physical distance but with the help of technology, equipment, and tools they are linked together. E-learning requires consideration of the computer literacy of academic staff and students as well as access to computers and high-speed internet infrastructure. Students and faculty must have skills sufficient for them to register, communicate, download, view, and be tested. E-learning technologies offer the learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives.^[9-11]

E-learning can be supported through different forms such as web-based learning, computer-based learning, or virtual classrooms and content delivery through e-networks, audio or video tape, satellite TV, video conferencing, i-pods, E-mails, wikis, and wireless mobile technology. Learning is the process that takes place from the student’s perspective as a result of instructional strategies. Emphasis will be placed on increasing student involvement and making them responsible for their own learning. E-learning offers various benefits such as increased accessibility to information, better content delivery, personalized instruction, content standardization, accountability, self-pacing, interactions in peer groups, confidence building, and increased convenience.^[12]

In traditional lecture learning, 33 min after a lecture is completed, students only retain 58% of the material presented. By the 2^nd day, only 33% is retained, and 3 weeks after the course is completed, only 15% is remembered.^[13] While in e-learning lecture, course material can be accessed several times, from any place, and at any time if something is forgotten which allows students to remember most of the information delivered that they are required to learn in particular course.

The most notable disadvantage of e-learning is its lack of social interaction and loss of human touch. Many students need social interaction to perform academically well and thus find distance learning difficult. There are types of training that simply cannot be taught through e-learning, these are known as soft skills. These include interpersonal skills, verbal, communication, leadership, and initiative. E-learning does not offer the student with the same opportunities of explanation and clarification that occur in face-to-face interaction and feedback in an e-learning environment may be delayed or text-mediated or simply too context-dependent to be able to be recreated through a telephone call or E-mail 2 days later.

Why e-learning in orthodontic education? For visualizing concepts in the form of patient simulations and multimedia instructions, thus supporting the preclinical and clinical teaching and learning; audio/video seminars; information sharing and collaborative working environments through online projects; tracking the learner activities and mastery of the material through formative assessment (e.g., quiz scores); providing immediate feedbacks, thus augmenting the self-paced and self-directed learning; Motivating the students toward learning.^[12,14]

Blended learning

Online learning and traditional face-to-face learning have their own respective strengths and weaknesses. Neither is better but rather they are complementary. Blended learning was introduced to take the benefits of both learning methods. Blended learning in the broadest sense can be defined or conceptualized as a wide variety of technology/media integrated with conventional face-to-face classroom activities. Blended learning involves the appropriate blend of different components which includes courses, contents, feedback, etc. Blended learning can solve the problems associated with most e-learning models. In blended learning, faculty must know when to shift gears, add new tasks, and when to let the learners to explore their own interests.^[15]

The integration of blended learning (physical and virtual) into dental education can catalyze the shift toward applying constructivist learning theory, where faculty will no longer serve as the distributors of knowledge content but will become more involved as facilitators of learning and assessors of competency. The students should complete e-modules of self-learning on a given topic before coming to the classroom. The classroom-based learning is then used for the interactive elements of the learning, such as role-plays and discussion. By conducting part of the learning asynchronously, part of it by synchronously through online learning, and only the most interactive part in a classroom learning, the information can be delivered over a longer period and thus improves the student retention. Blended learning is also a viable way to augment faculty resources and to help overcome faculty shortages.^[15]

Learning pyramid indicates different levels of retention for different activities. According to learning pyramid, learners retain approximately 90% of what they learn when they teach someone else/use immediately; 75% when they practice what they learned; 50% when they are engaged in a group discussion; 30% when they see a demonstration; 20% from audio-visual; 10% from reading; and 5% from lecture.^[16,17] The goal of blended learning is to provide the most efficient and effective instruction experience by combining delivery modalities. It may involve usage of computer, cellular or smart phones, satellite television channels, video conferencing, and other emerging electronic media.

A comparison table is provided which summarizes the various teaching and learning methods in an education system [Table 1].

Effectiveness

There are four important questions about effectiveness of e-learning that have been addressed in this review. (1) Whether the e-learning classes are better than or at least as good as face-to-face classroom learning? (2) Is blended learning more effective than only e-learning or face-to-face learning? (3) Are classes conducted through e-learning equally effective for theoretical learning and practical manual skills? (4) Is e-learning (distance learning) effective for continuing orthodontic education for residents and practicing orthodontists?

First, whether the e-learning classes are better than or at least as good as face-to-face classroom learning? Information emerging from published studies in orthodontic education has indicated that E-learning classes are better than face-to-face in some studies and in few studies at least as good as face-to-face classroom learning. Turner and Weerakone^[20] and Clark et al.^[21] found that no significant difference in knowledge gain between the hypertext system versus conventional system on the subject of principles of cephalometrics, tracing technique, and analysis. Luffingham^[18] concluded in his study that the CAL presentation of orthodontic clinical data is an effective and popular addition to traditional face-to-face learning. Lowe et al.^[24] found that undergraduate dental students can learn to use index of orthodontic treatment need as well or better when using a CAL program compared with a lecture. Irvine and Moore^[19] found that the CAL group performed significantly better on the posttest than did the lecture group in learning mixed dentition analysis. Aly et al.^[27] found that the instructional interactive multimedia program to be at least as effective as the standard lecture of the orthodontic curriculum for undergraduate training in orthodontics and stated that the CAL is an effective way of increasing knowledge, understanding, and application in teaching orthodontics. Komolpis and Johnson^[25] found that there were no statistically significant differences between mean test scores and concluded that web-based digital orthodontic records were as effective in teaching clinical orthodontic diagnosis as were conventional records. Nurko and Proffit^[28] found that web-based self-instruction plus small-group seminars coordinated by a course leader is at least as effective as traditional lectures. This approach can become a way to share faculty resources among schools so that an instructional expert in a particular area could manage the teaching of that subject at several institutions. For maximum effectiveness, the distant faculty member should be involved in both the development of the instructional modules and the small-group discussions. Mulgrew et al.^[32] found that travel commitments for trainees have reduced as a result of introducing the web-based resource, but not as expected. Demands on academic staff have not reduced but have changed. The resource has had positive effects on postgraduate orthodontic teaching and learning. Linjawi et al.^[33] assessed an online undergraduate orthodontic e-course design and concluded that orthodontic e-course is effective as a learning resource for the students. Ludwig et al.^[38] investigated the tracing skills of traditional learning group and two e-learning groups after all undergraduate students underwent traditional training of cephalometry consisting of lectures and tutorials. They found that both e-learning groups improved more than the traditional group and blended learning produced better learning outcomes compared to using a traditional teaching method alone.

Till date, only one study states that face-to-face conventional tutorial learning is better than CAL. Hobson et al.^[22] used a text-based CAL package designed to teach orthodontic assessment and basic principles of treatment planning and compared with conventional teaching. Both the student groups made significant gains in knowledge. However, students who were taught by the conventional tutorial made a significantly greater gain than those taught by CAL.

The second question with regard to effectiveness is whether blended learning is more effective than only e-learning or face-to-face learning? Few studies stated that blended approach using both traditional face-to-face learning and e-learning is the best method of learning and teaching. Retrouvey and Finkelstein^[31] evaluated the use of blended learning in orthodontic diagnosis, which incorporated multimedia and self-directed learning module into undergraduate curriculum. The goal was to bridge the gap between theoretical knowledge and the practical skills needed to be a successful dentist. Multimedia program on orthodontic diagnosis was well received by students as it allows them to learn at their own pace and apply the knowledge by carrying out simple but effective exercises. Student’s performance was better using the technology than they did after traditional lectures. Bains et al.^[35] found that there is no statistically significant difference between face-to-face learning and blended learning. E-learning alone was less effective when delivering Cephalometric education to undergraduates.

The third question with regard to effectiveness is whether e-learning is equally effective for theoretical and practical learning. The advantages of e-learning observed in the theoretical fields of orthodontics were not achieved in the educational procedures for manual skills. Schorn-Borgmann et al.^[40] evaluated the effect of online demonstrations concerning the quality of three orthodontic appliances (Schwarz Plate, U-Bow Activator, and Fränkel Regulator) manufactured by undergraduate dental students. Fifty-four participants were randomly assigned to one of the three groups: conventional lectures, conventional lectures plus written online material, and third group with access to resources of groups one and two plus access to online video material. No significant differences were found between the groups. They concluded that students could use additional time and course-independent e-learning resources did not increase the outcome quality of the orthodontic appliances.

The fourth question with regard to effectiveness is whether e-learning (distance learning) is effective for continuing orthodontic education for residents and practicing orthodontists? Miller et al.^[30] found that distance learning based on the observation of recorded seminars, and follow-up interaction is an acceptable method of instruction that can allow residents and practicing orthodontists to access various materials and experts, and perhaps help to ease the strains of current faculty shortages. Video conferencing received the highest ratings, telephonic interaction was a close second in mean scores, and Internet chat was a distant third. All residents stated that they would like to be taught through distance education again. In a study by Klein et al.,^[36] blended approach was judged to be effective as compared to distance e-learning that allows residents to access various experts, supplement traditional instructor-led training, and eases the strain of current faculty shortages. Marsh et al.^[23] concluded that for orthodontists who are comfortable with the concept of computer instruction, a high-level computer instructional program can change behavior in a clinical setting and additional graphics to improve the appearance of the teaching program are unnecessary and perhaps counterproductive.

Efficiency, acceptability, and appeal

The initial investment required to develop a highly interactive e-learning course can be high; later there were more savings due to a reduction in cost of classroom facilities, faculty, and cost of printed materials. Rosenberg et al.^[34] found that the improved performance on the orthodontic diagnosis electronic tutorial (ODET) test was noted for students who reported longer times spent reviewing the tutorial. Mulgrew et al.,^[32] found improvements in the flexibility and efficiency of learning with modular teaching program and students continued to value the opportunity to interact face-to-face with their teachers and peers.

Numerous studies performed through questionnaires showed that student’s attitude and acceptance toward the use of e-learning was favorable, and blended learning is always rated high in orthodontic undergraduate and postgraduate training. Irvine and Moore^[19] found that student’s attitude toward the use of CAL program was favorable in learning-mixed dentition analysis. Turner and Weerakone^[20] concluded that students liked and enjoyed the hypertext system in learning principles of cephalometrics and analysis, however; Clark et al.,^[21] in their study found that the 3/4 of students said CAL was enjoyable and 1/4 of students said its time consuming and faced difficulty in following the course. Komolpis and Johnson^[25] found that attitudes of students toward the design and set-up of the website, in learning a preclinical orthodontic course were positive. Aly et al.^[26] concluded from his study that majority of undergraduate and postgraduate students were very enthusiastic about interactive multimedia courseware (74/100) and students experienced that courseware was very helpful in understanding the orthodontic curriculum (98/100). Linjawi et al.^[33] found that student responded “very positive” to “positive” for orthodontic e-course design, course delivery, and course outcome. The orthodontic e-course was seen by most students (86%) as an adjunct and not a replacement of the traditional teaching methods. 34.4% of subjects felt that it should be as an optional supplement and 51.6% felt that it should be integrated with the undergraduate orthodontic curriculum. Rosenberg et al.^[34] found that students are not prepared to replace lectures with CAL tutorials and appealed that the ODET should continue to be used along with traditional learning. Naser-ud-Din^[39] found high acceptance rate, greater confidence in the application of clinical skills with Scenario Based Learning Interactive (SBLi^®) software (Identic Pty Ltd.) for orthodontics postgraduate training. E-modules demonstrated high compatibility with the learning styles of the participants. Bains et al.^[35] found that undergraduate students were more positive toward blended learning than face-to-face learning or e-learning alone in learning cephalometrics. Bednar et al.^[29] found that the acceptability of the distance seminars appeared to be influenced by the instructor’s personality and teaching style in facilitating interaction, the seminar subject, the residents’ comfort level in dealing with this technology, and the sequence for interaction versus observation. Klein et al.,^[36] concluded from their study that the blended approach compared to distance learning was judged to be acceptable and enjoyable; faculty members were somewhat more enthusiastic about the experience than were residents. Most residents and faculty agreed that they would like to use this approach to distance learning again. Retrouvey and Finkelstein^[31] concluded from their study that student’s such as the concept of blended learning and their rate of learning and retention of knowledge seem superior to those using conventional lecture. Ireland et al.^[37] found that the Wiki topic teaching is a useful tool in the teaching of postgraduate orthodontics providing variation and a more learner-centered approach. Students felt writing the Wikis was useful for teamwork, created a body of work in a live format that would be useful for revision and was a welcome variation on traditional teaching methods.

Self-assessment

Aly et al.^[26] found interactive computer software package to be a user-friendly way for both undergraduates and postgraduates to understand the orthodontic curriculum. They concluded that e-learning program provided the dental undergraduate and postgraduate students with an interactive means of self-study and self-evaluation.

Gender difference

Rosenberg et al.^[34] found that there was a difference in lecture test scores between male and female students, and no significant difference in mean ODET test scores; this might be explained by the sex differences in terms of learning style preferences, with men preferring self-instruction more than women. Linjawi et al.^[33] found that there was no significant difference between genders in learning orthodontic e-course for undergraduate students.

Future research

There is limited evidence on the effectiveness and efficiency of both e-learning and blended learning in orthodontic education. The new teaching and learning technologies should be tested thoroughly before implementing into the education system. Experiences of both faculty and student should be investigated on a large scale for implementation of e-learning or blended learning in academic institutions. Universities should invest into research in the area of e-learning and blended learning in orthodontic education. There is also a need to provide professional development for faculty who will be teaching both physically and virtually. E-learning would increase the use of mobile and wireless technology. Mobile blended learning technologies will also be able to make learning more easily accessible for a wider range of individuals, thereby creating greater opportunities for lifelong learning. Future research should be including mobile blended learning technologies in teaching of orthodontics.