ABSTRACT
Purpose/Objectives
This study aimed to develop a virtual reality simulation (VRS) program that is based on a scenario, training dental hygiene students in the intraoral bisecting angle technique. We tested the effectiveness of VRS in education using performance confidence (PC), clinical competency (CC) and learning satisfaction (LS).
Methods
This study developed a program based on performance competency and conducted a single‐group pretest–posttest experiment to test its effectiveness. Thirty‐three second‐ and third‐year dental hygiene students were recruited from a single dental hygiene university. We confirmed each item's validity based on the content validity index (CVI) and compared differences in PC, LS and CC before and after training.
Results
Significant differences were observed in PC, which increased from a score of 78.51 ± 9.0 before training to 89.33 ± 7.03 after the first training and to 94.00 ± 5.75 after the second training (p < 0.001). CC increased significantly from 69.92 ± 9.46 before training to 87.04 ± 4.43 after training. LS also increased significantly, from a score of 94.15 ± 8.15 before training to 97.45 ± 4.71 after training (p = 0.002).
Conclusions
Dental hygiene students' PC, CC and LS improved after training using a VRS for the intraoral bisecting angle technique. VRS training is an effective educational tool that can complement traditional skills training; such training programmes should be developed not only for dental hygiene courses but also for the education and skill enhancement of other dental professionals.
Keywords: dental, education, radiography, virtual reality
1. Introduction
In dentistry, radiography is used to visualise dental and alveolar bone structures inside and outside the mouth that are difficult to see with the naked eye. Dental professionals use radiography to identify pathological findings inside the mouth and quickly obtain information related to treatment planning and prognosis [1, 2]. Dental hygienists in Korea are responsible for the prevention of dental and oral diseases and the maintenance of oral hygiene. Specific duties include scaling, fluoride application, placement and removal of temporary filling materials and orthodontic appliances, taking dental impressions and performing intraoral diagnostic radiography [3]. Since dental hygienists perform most of the periapical radiography taken in dental hospitals and clinics, they may be exposed to radiation risks. The radiation dose can be reduced in two ways. First, changes to radiography equipment, such as using a rectangular rather than a round collimator, can reduce the radiation dose [4]. Additionally, using a low‐dose protocol for cone beam computed tomography can reduce patients' radiation exposure, thereby minimising the associated health risks [5]. Second, radiation exposure can be reduced by conducting fewer scans for artefacts, which requires dental professionals to be highly proficient [6, 7]. The reject or image rejection rate represents the proportion of failed imaging attempts out of the total number of images acquired. Recent systematic literature reviews indicate an approximately 16.4% rejection rate. Obtaining error‐free images with minimal radiation exposure ensures accurate interpretation and increased radiation safety. Therefore, radiography experts' technical proficiency must be improved to achieve error‐free imaging results [8].
There are two common techniques to obtain intraoral radiographs in a dental office. The bisecting angle technique involves irradiating the central ray perpendicular to an imaginary line that bisects the angle formed by the long axis of the tooth and the film. Because the long axes of each tooth are different, the central ray must be irradiated according to the position of each tooth to obtain accurate images. This requires high skill and proficiency. The paralleling technique has less strenuous skill requirements. In this technique, the X‐ray holder facilitates the intraoral placement of the receptor, and the attached ring guides the X‐ray tube head to the correct position and angulation for capturing a high‐quality image. However, the parallel technique may be challenging to implement in cases where the patient is unable to retain the film holder in the mouth. Additionally, it has several drawbacks, including potential discomfort, pain, a gag reflex and damage to the mucosal tissues [9]. Moreover, a recent report indicated that it may often be inappropriate for people of Asian ethnicities due to anatomical differences that cause challenges in correctly fitting the film holders intraorally in the maxilla [10].
The Medical Service Act of Korea stipulates that dental radiographers, dentists, radiologists and dental hygienists can be appointed as diagnostic radiation safety managers by the amendments of the 2001 Rules for Safety Management of Diagnostic Radiation Generators. The number of dental hygienists registered as radiation‐related service workers was 11 452 in 2018 and 12 502 in 2022; this trend relates to the increasing radiation‐related responsibilities of dental hygienists in medical institutions [11]. The diagnostic radiation generators used for training were originally excluded from these regulations, but new requirements indicate that they must be in radiation safety management zones and are subject to the Act on Nuclear Safety Information Disclosure and Communication. Instructors and students participating in oral radiology training must complete health examinations, exposure control and safety education and training by the qualification requirements for working in radiation management zones [12]. Moreover, challenges in operating training programmes include licensing for special equipment needed for operating radiation training, the cost of equipment for exposure control, management of instructor/student qualifications and educating and training instructors and students [13].
In clinical simulation practice, learners can acquire skills through indirect experience using replication of special circumstances. While training using high‐fidelity simulators is common, students may struggle to repeatedly perform the training because of the costs of producing standardised patients, as well as equipment and space constraints [14]. Therefore, finding effective training tools that can overcome these economic and physical challenges is necessary.
Extended reality (XR), a type of mixed reality that includes virtual reality (VR) and augmented reality (AR), uses computers to virtually simulate specific environments using three‐dimensional graphics and provide users with artificial sensory stimulation; they experience an environment or situation as if it were to occur in real life [15]. In particular, students can use VR for self‐led learning without causing harm or pain to patients. Therefore, VR is a cost‐effective and safe environment for education and practice. VR media engages various senses, including sight, hearing and touch, and is expected to be an effective learning tool.
Currently, virtual reality simulation (VRS) programs are being developed in various medical and healthcare‐related education industries around the world, including programs for tooth extraction, implantation and oral and maxillofacial anaesthesia for dentists [16, 17], and programs for oral and maxillofacial anatomy and radiology for dental hygienists [18, 19]. Research is being conducted on radiology courses that incorporate VR education programs, and several studies have explored the application of XR technologies in the field of radiology; Gu [13] used an application to attach a personal mobile device to dental radiography equipment that used AR with training mannequins; Im [18] acquired radiographs using a 360° camera on a head‐mounted display (HMD) to enable the indirect radiography experience and reported enhanced learning immersion and confidence. However, students may struggle with autonomous learning because instructors must intervene in practice, and VR using 360° imaging offers only an indirect experience of recorded VR videos. Also, previous studies have used subjective self‐assessment tools in evaluations, making confirmation of objective differences in performance abilities difficult. There is therefore a lack of evaluation regarding the validation of VRS as an educational medium.
This study developed a VR‐based program that reproduced infection control, imaging techniques, imaging outcome assessment and communication throughout the complete process while performing the bisecting angle technique. This study evaluated VR as a learning medium to supplement conventional mannequin practice by allowing students to experience infection control and communication processes that are difficult to experience in conventional practice. It also addressed the limitation of being unable to practice intraoral radiography due to entry restrictions in the radiology room. This study investigated differences in performance confidence (PC), learning satisfaction (LS) and clinical competency (CC) before and after VR‐based training to determine if VR training can complement traditional oral and maxillofacial imaging skills training.
2. Materials and Methods
2.1. Research Design
This study, approved by the institutional review board of OO University (1041849–202 208‐SB‐144‐02), was conducted using a single‐group, pre‐ and postexperimental design. To develop a VRS training program based on scenarios using the bisecting angle technique for oral and maxillofacial imaging and test the program's effectiveness, this study used a single‐group, pretest–posttest experimental design. The program was developed after conducting expert validation through consultation with three dental hygiene professors and two clinical dental hygienists with more than 10 years of experience; items with a content validity index of ≥ 0.8 were selected [20]. Also, the items were revised by collecting expert opinions using open‐ended questions; after 1 week, the revised items underwent a second expert validation to select the final performance competencies. The VR program and the scenarios were completed based on the final performance competencies.
2.2. Modifications and Additions to the Existing Program
The training program was developed as shown in Figures 1 and 2. The study was conducted in collaboration with VRAD, a company that develops medical professional software utilising VR and information and communication technology (ICT) to overcome the economic and physical limitations of traditional medical education. The program analysed the bisecting angle technique in the dental radiography simulator (DRS) to improve the existing program. The existing DRS program only simulates the techniques in the X‐ray shooting stage, and participants cannot perform the entire practice in the bisecting technique. It also produces errors during the imaging process, such as inconsistent reading results, especially cone cut and horizontal angle; as such, imaging results differ from actual results. Therefore, the newly developed program addressed imaging errors and inconsistencies in acquired images. To perform infection control practice in the X‐ray room, infection control item supplies such as hand sanitisers and gloves (multipurpose and medical gloves), personal protective equipment (PPE), and infection control practice processes were added to the program. To enhance realism, the prepared radiography equipment and supplies used for infection control were similar to the actual supply. The specific modifications and additions are shown in Table 1.
FIGURE 1.
Virtual reality simulation education program process.
FIGURE 2.
Change in performance confidence, clinical competency and learning satisfaction. CC, clinical competency; LS, learning satisfaction; PC, performance confidence. Variables are converted to 100 points.
TABLE 1.
Summary of the modifications and additions to the existing program.
| Before | After | |
|---|---|---|
| The horizontal angle and beam‐centering errors that occur when the horizontal angle or cone cut is incorrect and is not reproduced |
|
|
| 4‐A horizontal angle error | 4‐B cone‐cut error | |
| No procedures for radiation safety and protection |
|
|
| 4‐C addition: wearing the TLD badge | 4‐D addition: placing the lead apron | |
| No procedures for infection control, such as wearing PPE, surface disinfection and application of barrier film |
|
|
| 4‐E provision of infection control supplies | 4‐F application of barrier film | |
| No procedure for performance competency and communication process |
|
|
| 4‐G provision of competency notification | 4‐H provision of communication subtitles | |
2.3. VRS Program Development
For the final program, scenarios were developed to reproduce the process of trainee communication and performing each stage of the bisecting angle technique in the VR simulator based on the final performance competencies. The developed communication scenarios were provided with text subtitles in the VR to enable the trainees to communicate according to each stage of performance competency. The avatar acting as the patient used audio recordings to provide feedback in voice, considering the average time required for the trainees to audibly read the captions. In addition, clues were provided through the dental charts in the program to enable the trainees to determine, on their own, the patient's personal information, systemic condition, dentition, etc. The clinical scenario in the program involves a male patient born in 1963 and includes the following physician findings: radiography is needed for sharp pain and discomfort to cold/hot stimulation in the maxillary first and second molars (or mandibular first and second molars).
2.4. VRS Program
The participants in this study were required to meet the following inclusion criteria: having been eligible to access radiation management zones after completing a health examination and radiation safety management training and receiving a TLD badge for exposure management; the instructor having eligibility to shoot the X‐ray machine in a radiation management zone after completing a health examination, having radiation safety management training and receiving a TLD badge for exposure management. As for radiation safety, the instructor was present during each training session; radiation generators and safety management equipment in the radiation management zone were checked, and the radiation dose was measured and recorded before proceeding with the study.
Before VR education, theoretical remind education was executed. Bisecting angle technique training material was distributed 1 week before the VR Program via Email, and only those who completed it were allowed to participate in the VR training. As participants were second‐ and third‐year students who had been trained on the bisecting angle technique for maxillofacial imaging 1 month and 1 year earlier, respectively, pre‐education was used to supplement each participant's training level. For the pre‐education, the participants practised for 10 min (5 min on maxillary right first and second molars and 5 min on mandibular left first and second molars of a phantom) and finished the pre‐education. After the preeducation, a preassessment of the phantom was conducted to evaluate clinical competency. VR education was executed with Oculus Quest 2, an immersive virtual reality device worn on the head. It is equipped with four front‐facing cameras that allow perception of the external environment through movements and handheld controllers that detect external environments through buttons and movements. Before the VR training, the participants learned how to wear the headset and operate the controllers. In the first VR training session (basic mode), the participants practised for 25 min each on the maxillary right first and second molars and mandibular left first and second molars, providing performance competency prompts and clues with communication subtitles. When the trainees experienced performance difficulties in the program, the instructor connected the headset to a computer to evaluate and resolve the problem. Upon completion of the first VR training, a survey was conducted on PC and LS. The second VR training session (practical mode) took place one week later. The participants practised for 25 min on each of the previous sections with performance competency prompts, clues and communication subtitles removed. After completing the VR training, each trainee's VR clinical competency evaluation was assessed. During each trainee's assessment, other trainees observed their performance through a computer monitor. After completing all VR training, posttraining performance on the phantom was assessed for clinical competency. Debriefing was conducted on VR education in groups of three after completion of the entire education program, lasting approximately 20 min per group.
2.5. Participants
The participants in this study consisted of second and third‐year dental hygiene students from a single dental hygiene college in Wonju, Gangwon‐do, who were informed about the purpose of the study and voluntarily consented to participate. G‐power 3.1.9.7 program was used to calculate the sample size at a significance level (α) of < 0.05, power (1‐β) of 0.80 and effect size of 0.50. The results showed that the minimum sample size was 27. A total of 33 students participated in the study.
2.6. Study Variables
2.6.1. General Characteristics
General characteristics were surveyed, including gender, grade in school, age, experience with bisecting angle technique theory and practice, experience with VR, experience with simulation training, expectations for VR‐based training, satisfaction with major and satisfaction with clinical practical training.
2.6.2. Performance Confidence
PC consisted of core items that needed to be performed for the bisecting angle technique for oral and maxillofacial imaging based on performance competencies verified by the expert validation. Twenty items covered the processes before and after X‐ray shooting and communication. Each item was rated on a five‐point Likert scale, collected through a questionnaire, with higher scores indicating higher confidence in performing the bisecting angle technique.
2.6.3. Clinical Competency
CC was classified into phantom skills and VRS. The scores were used to analyse the changes in performance competency between before and after training. The evaluation of CC was conducted by a single researcher, who observed and scored learners' performance using the competency checklist for the bisecting radiography technique before and after the intervention. A total of 20 items were assessed on a 0‐ to 2‐point scale based on performance, by the established rubric. The grading criteria were categorised as follows: correct performance (2 points), mostly correct with minor errors (1 point) and incorrect performance (0 points). The clinical competencies assessed in VR included items that could not be performed on the phantom (e.g., communication, infection control), so the results are not presented. Instead, they were used during the debriefing for feedback after the students completed the VR training. The participant's clinical competency abilities were coded and identified for anonymous processing. The same instructor re‐read the imaging results 1 week later using a test–retest method to confirm internal consistency. The correlation coefficient between the test and retest of the participants was 0.878 (p < 0.001).
2.6.4. Leaning Satisfaction
LS was measured using an existing scale [21] that had been revised and updated for this study. LS comprised items related to suitability (n = 7), achievement (n = 5), learner attitude (n = 1) and learner satisfaction (n = 7). Each item was rated on a five‐point Likert scale through a questionnaire, with higher scores indicating higher LS.
2.7. Statistical Analysis
The collected data were analysed using SPSS Version 26.0 (IBM Corp, Armonk, NY, USA), with a significance level (α) of 0.05 for determining statistical significance. Content validity was verified through the content validity index (CVI). Descriptive statistics, including frequencies, percentages, means and standard deviations, were used to calculate the general characteristics of the research participants. Differences in participants' performance confidence before and after the educational programme were analysed using repeated measures ANOVA, while differences in clinical competency and learning satisfaction were analysed using paired t‐tests.
3. Results
3.1. General Characteristics
Most of the participants were women, and the mean age was 20.54 ± 1.32 years. There were 19 (57.6%) second‐year and 14 (42.4%) third‐year dental hygiene students. All participants (100%) knew about the bisecting technique theory and practicum training.
3.2. Change in Performance Confidence
The mean confidence level before X‐ray shooting significantly increased from 4.14 ± 0.55 before training to 4.66 ± 0.33 after the first session, and 4.87 ± 0.25 after the second session (F = 48.75, p < 0.001). Confidence during X‐ray shooting also significantly increased, from 3.30 ± 0.55 before training to 4.00 ± 0.48 after the first session, and 4.31 ± 0.47 after the second session (F = 75.99, p < 0.001). Confidence after X‐ray shooting similarly increased, from 4.04 ± 0.67 before training to 4.63 ± 0.40 after the first session, and 4.80 ± 0.32 after the second session (F = 41.62, p < 0.001). Additionally, communication performance confidence significantly increased, from 4.14 ± 0.55 before training to 4.54 ± 0.49 after the first session, and 4.76 ± 0.39 after the second session (F = 53.71, p < 0.001). (Table 2), (Figure 2).
TABLE 2.
Changes in performance confidence.
| Item | Pretest M ± SD | Posttest 1 M ± SD | Posttest 2 M ± SD | F | p |
|---|---|---|---|---|---|
| Steps before X‐ray shooting | |||||
| Check and prepare the necessary materials for the bisecting angle technique in advance | 4.12 ± 0.69 | 4.60 ± 0.65 | 4.84 ± 0.36 | 12.997 | < 0.001** |
| Necessary infection control can be performed before filming | 4.39 ± 0.60 | 4.78 ± 0.34 | 4.87 ± 0.33 | 8.56 | 0.001* |
| Can explain the purpose and necessity of radiography to patients | 3.87 ± 0.73 | 4.43 ± 0.50 | 4.84 ± 0.36 | 23.19 | < 0.001** |
| Information necessary for the patient can be collected | 4.12 ± 0.78 | 4.60 ± 0.49 | 4.90 ± 0.29 | 20.46 | < 0.001** |
| Can explain the purpose and necessity of the X‐ray procedure | 4.00 ± 0.75 | 4.60 ± 0.55 | 4.84 ± 0.44 | 18.38 | < 0.001** |
| Can select the dose appropriate for the subject's age and target teeth | 3.75 ± 0.14 | 4.69 ± 0.52 | 4.87 ± 0.33 | 14.52 | < 0.001** |
| Radiation safety can be explained, and one can be made to wear lead apron | 4.36 ± 0.65 | 4.72 ± 0.45 | 4.84 ± 0.36 | 6.60 | 0.004* |
| The subject can be identified, and foreign objects can be removed | 4.45 ± 0.61 | 4.81 ± 0.39 | 4.90 ± 0.29 | 8.77 | < 0.001** |
| Total | 4.14 ± 0.55 | 4.66 ± 0.33 | 4.87 ± 25 | 48.75 | < 0.001 ** |
| Steps during X‐ray shooting | |||||
| The digital sensor, through the irradiation, can be positioned to fit the target tooth | 3.57 ± 0.66 | 4.06 ± 0.65 | 4.45 ± 0.56 | 26.09 | < 0.001** |
| The vertical and horizontal angles of the acetabulum can be adjusted to target tooth | 3.36 ± 0.60 | 4.00 ± 0.61 | 4.27 ± 0.62 | 20.25 | < 0.001** |
| Can check the digital sensor and the virtual bisector of the tooth's long axis | 3.39 ± 0.70 | 3.87 ± 0.69 | 4.33 ± 0.69 | 20.94 | < 0.001** |
| Can shoot clearly without errors in the shooting results | 2.42 ± 0.79 | 3.48 ± 0.79 | 3.75 ± 0.79 | 50.88 | < 0.001** |
| Can check the shooting results to decide whether to end shooting or reshoot | 3.75 ± 0.83 | 4.60 ± 0.55 | 4.75 ± 0.43 | 19.03 | < 0.001** |
| Total | 3.30 ± 0.55 | 4.00 ± 0.48 | 4.31 ± 0.47 | 75.99 | < 0.001 ** |
| Steps after X‐ray shooting | |||||
| Necessary infection control can be performed after radiography | 4.36 ± 0.60 | 4.81 ± 0.39 | 4.93 ± 0.24 | 15.19 | < 0.001** |
| Can easily and appropriately explain medical terminology to patients | 3.72 ± 0.87 | 4.45 ± 0.61 | 4.66 ± 0.54 | 17.62 | < 0.001** |
| Total | 4.04 ± 0.67 | 4.63 ± 0.40 | 4.80 ± 0.32 | 41.62 | < 0.001 ** |
| Communication | |||||
| The procedure can be explained to the patient in an easy‐to‐understand manner | 4.03 ± 0.68 | 4.45 ± 0.56 | 4.72 ± 0.51 | 14.85 | < 0.001** |
| Can check whether the patient understands the explanation of the procedure | 3.96 ± 0.76 | 4.36 ± 0.74 | 4.72 ± 0.45 | 13.31 | < 0.001** |
| Check whether the patient understands the explanation of the procedure | 4.06 ± 0.78 | 4.51 ± 0.75 | 4.78 ± 0.48 | 16.84 | < 0.001** |
| This can be performed while listening to the patient | 4.30 ± 0.68 | 4.66 ± 0.59 | 4.78 ± 0.341 | 11.54 | < 0.001** |
| Able to communicate with patients positively and treat them kindly | 4.36 ± 0.74 | 4.72 ± 0.51 | 4.81 ± 0.46 | 10.41 | < 0.001** |
| Total | 4.14 ± 0.55 | 4.54 ± 0.49 | 4.76 ± 0.39 | 53.71 | < 0.001 ** |
Note: By repeated measure ANOVA.
p < 0.05.
p < 0.001.
3.3. Change in Clinical Competency
Changes in clinical performance during the evaluation stage are shown in Table 3. Dichotomous items were scored as 2 or 0 points, while non‐dichotomous items were scored as 2, 1 or 0 points. The results table presents only correctly performed cases before and after training, excluding partial or incorrect performances (0 and 1 points). Before training, three participants (9.1%) reported ‘no extension of treatment time’; after training, this increased to 30 participants (90.9%). Twenty‐nine participants (87.9%) reported ‘no reduction in treatment time’ before training, with 32 (97%) reporting it after. ‘No other issues’ were reported by 13 participants (39.4%) before training and by 27 (81.8%) after (Table 3), (Figure 2).
TABLE 3.
Change in clinical competency performed accurately.
| Item | Pretest N (%) | Posttest N (%) |
|---|---|---|
| Preparation stage | ||
| Wears a TLD badge a | 33 (100.0) | 33 (100.0) |
| Performs hand hygiene a | 3 (9.1) | 33 (100.0) |
| Adjusts the patient's posture a | 22 (66.7) | 29 (87.9) |
| Select the dose appropriate for the patient's age a | 33 (100.0) | 33 (100.0) |
| Selects the dose appropriate for the X‐ray of the tooth a | 25 (75.7) | 33 (100.0) |
| Bisecting angle technique stage | ||
| Covers the surface of the digital sensor a | 8 (24.2) | 33 (100.0) |
| Positions the digital sensor at the centre of the tooth b | 18 (54.5) | 15 (45.4) |
| Positions the digital sensor parallel to the long axis of the target tooth b | 24 (72.7) | 30 (90.9) |
| Positions the X‐ray tube close to the facial skin a | 11 (33.3) | 20 (60.6) |
| Adjusts the digital sensor to the centre of the X‐ray tube b | 11 (33.3) | 20 (60.6) |
| Correctly adjusts vertical angle b | 18 (54.5) | 20 (60.6) |
| Correctly adjusts horizontally angle b | 15 (45.5) | 11 (33.3) |
| Reconfirms the bisecting line a | 8 (24.2) | 33 (100.0) |
| Evaluation stage | ||
| Accurately obtained two molars b | 4 (12.1) | 7 (21.2) |
| No extension occurred a | 3 (9.1) | 30 (90.9) |
| No shortening occurred a | 29 (87.9) | 32 (97.0) |
| No cone cut occurred a | 2 (6.0) | 2 (6.0) |
| No overlapping occurred a | 31 (93.9) | 33 (100.0) |
| No exposure failure occurred a | 32 (97.0) | 32 (97.0) |
| No other issues present b | 13 (39.4) | 27 (81.8) |
Graded as 2 or 0.
Graded as 2–0.
3.4. Learning Satisfaction After VRS Training
Learning satisfaction increased significantly, from 94.15 ± 8.15 before training to 97.45 ± 4.71 after the first training (t = −3.37, p = 0.002). Specifically, learning achievement significantly increased from 4.45 ± 0.58 after the first training to 4.82 ± 0.38 after the second training (t = −15.05, p < 0.001) (Table 4), (Figure 2).
TABLE 4.
Changes in learning satisfaction by item.
| Item | Pretest | Posttest | t | p |
|---|---|---|---|---|
| Suitability of the learning structure | ||||
| Training was necessary for bisecting the angle technique | 4.76 ± 0.44 | 4.91 ± 0.29 | −2.39 | 0.023* |
| Educational textbooks and materials are appropriately structured | 4.79 ± 0.42 | 4.82 ± 0.39 | −0.44 | 0.66 |
| The content of the training was accurate | 4.76 ± 0.61 | 4.85 ± 0.36 | −1.00 | 0.32 |
| The training time was appropriate | 4.85 ± 0.36 | 4.85 ± 0.36 | 0.00 | 1.00 |
| Training methods were diverse and effective | 4.70 ± 0.68 | 4.82 ± 0.39 | −1.07 | 0.292 |
| The training evaluation method of the training was reasonable | 4.64 ± 0.60 | 4.85 ± 0.36 | −2.51 | 0.017* |
| Was satisfied with the training's evaluation | 4.70 ± 0.64 | 4.85 ± 0.36 | −1.54 | 0.134 |
| Total | 4.74 ± 0.46 | 4.84 ± 0.31 | −1.73 | 0.093 |
| Achievement satisfaction | ||||
| The learning goal set through training was achieved | 4.61 ± 0.66 | 4.88 ± 0.33 | −2.06 | 0.048 |
| Theoretical knowledge about bisecting angle technique increased | 4.45 ± 0.67 | 4.85 ± 0.36 | −4.07 | < 0.001** |
| Skills for bisecting angle technique increased through training | 4.45 ± 0.79 | 4.79 ± 0.42 | −2.60 | 0.014* |
| The ability to cope with the bisecting angle technique increased | 4.36 ± 0.78 | 4.79 ± 0.60 | −3.44 | 0.002* |
| The ability to perform the bisecting angle technique in clinical practice increased | 4.39 ± 0.70 | 4.82 ± 0.39 | −3.97 | < 0.001** |
| Total | 4.45 ± 0.58 | 4.82 ± 0.28 | −1.73 | < 0.001 ** |
| Learner attitude | ||||
| Actively participated in education | 4.88 ± 0.33 | 4.85 ± 0.36 | 0.57 | 0.572 |
| Learner satisfaction | ||||
| I am satisfied with the instructional strategies | 4.85 ± 0.36 | 4.91 ± 0.29 | −1.00 | 0.325 |
| I would like to recommend education to other students | 4.91 ± 0.29 | 4.94 ± 0.24 | −1.00 | 0.325 |
| The training content was interesting | 5.00 ± 0.00 | 4.94 ± 0.24 | 1.44 | 0.160 |
| The training was a useful learning experience | 4.91 ± 0.38 | 4.94 ± 0.24 | −0.57 | 0.572 |
| The feedback I received during training was helpful | 4.64 ± 0.74 | 4.94 ± 0.24 | −2.55 | 0.016* |
| Education is helpful in clinical practice | 4.70 ± 0.64 | 4.94 ± 0.24 | −2.27 | 0.030* |
| I am overall satisfied with my education | 4.82 ± 0.39 | 4.94 ± 0.24 | −2.10 | 0.044 |
| Total | 4.83 ± 0.34 | 4.93 ± 0.22 | −15.05 | < 0.001 ** |
Note: By paired t‐test.
p < 0.05.
p < 0.001.
4. Discussion
This study's results revealed that learners' performance confidence improved significantly after VR training, which aligns with a systematic review [22] that analysed the effects of VR‐based education on nursing students' learning satisfaction and performance confidence. Specifically, confidence related to imaging techniques, such as digital sensor placement, positioning of the X‐ray tube and adjustments of the vertical and horizontal angles, was notably enhanced. Students responded in the debriefing that repeated practice with a virtual laser, which indicated the vertical and horizontal angles of the cone in the basic mode, enabled them to learn to predict the position of the central ray. These results were consistent with the clinical competency evaluations that showed improvements such as digital sensor positioning, X‐ray tube positioning and angle adjustments. The bisecting angle technique requires the central ray to be projected perpendicular to an imaginary line bisecting the angle formed by the longitudinal axis of the tooth and the film; it is the most technically challenging for beginners due to the precision required in reproducing the correct angles [23]. However, students are legally restricted from operating the radiation switches during the conventional practicum, making it difficult for them to practice the bisecting technique within the limited clinical practicum time. VR programmes allow repetitive practice without these limitations, leading to enhanced technical proficiency in bisecting angle radiography. This finding aligns with Kim [24] on the utilisation of VR in radiographic training: Students reported that VR imaging could be learned and mastered more quickly compared to traditional phantom model imaging. However, considering the nature of VR training, where direct instructor intervention is not possible, such training should be preceded by foundational theoretical and practical courses [25]. Therefore, VR training can potentially enhance learning outcomes by allowing students with basic knowledge and practicum to practice techniques repetitively without an instructor, highlighting its potential benefit as an educational medium in dental hygiene, where sequentially remembering and performing procedures is crucial.
After the VR program, notable improvements were observed in clinical competency, particularly in infection control practices, such as pre‐procedural hand hygiene and the covering of digital sensor surfaces. The second and third‐year students who participated in this research program were cognisant of theoretical infection control methods and processes. However, as they had not experienced clinical practice in dental institutions, it is predicted that the methods and sequence of infection control were initially unfamiliar. Nonetheless, it is assumed that their ability in infection control improved through repeated learning and practice. Currently, in dental hygiene education in Korea, radiographic practicum training is performed on phantoms rather than on actual humans. Training on infection control is limited as it does not align with methods used on real patients. In the actual clinical dental radiology room, infection control is important due to frequent contact with saliva and blood. Dental radiography rooms are susceptible to cross‐infection due to potential exposure to saliva and blood during the insertion of a film in the patient's mouth. These radiography room settings often lack adequate training in infection control compared to those in dental procedure rooms and demonstrate poor compliance with using PPE and infection control practices [26]. Compliance with infection control practices in dental procedure rooms is higher among those with more training and knowledge [27, 28] and among staff with prior education on infection control in radiography rooms, who showed higher compliance with wearing PPE, such as face masks and gloves. Therefore, enhancing infection control training tailored to radiography room operations is crucial, including the consistent use of PPE, surface infection control and the disinfection and sterilisation of supplies. Ultimately, there needs to be consistency in infection control practices between these clinical and practical trainings. Moreover, an analysis of the images taken by students after the program confirmed a reduction in imaging errors. During the pre‐evaluation of clinical competency, there was a noticeable error, such as shortening and extension that resulted from incorrect vertical and horizontal angles, cone cut and overlapping. However, after the program, the bisecting technique errors were reduced. These findings corroborate previous results in which groups trained using VR exhibited superior performance throughout the tooth extraction process compared to those receiving conventional education, suggesting that VR training is effective in mastering key skills [29]. Studies have shown that equipping learners with a foundational understanding of theoretical knowledge and basic procedural techniques before providing a standardised practice regimen via VR significantly enhances learning outcomes and performance [25]. Ismailoglu [30] showed that educational outcomes improved when VRS training for intravenous catheter insertion was preceded by practical exercises on a plastic arm model. Similarly, Park [31] revealed that clinical performance in VR simulations was substantially enhanced when traditional nursing skills were rigorously practised (an average of four times) before VR training. Thus, this study emphasises that a synergistic approach that integrates VR with traditional skill training can substantially augment learning.
Students' learning satisfaction increased from 94.15 after the first session to 97.45 after the second session, consistent with previous findings that utilised VR in radiography training [13, 24]. Learning engagement and interest are key to boosting learning satisfaction and active class participation [31]. Learning immersion increases as simulations better resemble the real world [32]. In contrast to traditional phantom training, the VR utilised in this study closely mimics an actual clinical setting and includes interactive elements with patient avatars, which contributed to heightened student engagement. Furthermore, it is assumed that the novelty of VR as a new learning medium stimulated interest and attention in learners, which led to high learning satisfaction [33].
This study has several limitations that should be addressed in future research. First, since this program was based on a single scenario, more scenarios should be developed to offer students broader experiences. Specifically, scenarios about various oral and maxillofacial imaging techniques, other than the bisecting technique, should be developed. Second, since a single instructor conducted both the education and the assessment, it is necessary to expand the number of evaluators and to consider the evaluation methods in future studies. Third, during debriefing, students noted differences in the manipulation of actual X‐ray cones versus VR controllers. Therefore, even now, constant advances in technology recognising hand positions through headset cameras without the use of controllers, these issues could be resolved in the future.
This study aimed to validate the effectiveness of VR programs as an educational medium that allows dental hygiene students to practice procedural skills repetitively in a safe environment, thereby enhancing performance competencies in oral and maxillofacial radiology. Therefore, we chose a single‐group, pre–poststudy design rather than a comparative design that compares VR training with traditional training. While VR has been researched in various areas of dental hygiene, no past study has objectively assessed improvements in students' performance. Hence, this study is significant as it developed the program based on expert‐validated competencies and objectively assessed learner performance. In the future, studies should utilise additional parameters, such as duration and frequency of use, to validate the effectiveness of VR training in dental hygiene.
5. Conclusion
The utilisation of VR simulations has been shown to significantly enhance performance confidence, clinical competencies and learning satisfaction among dental hygiene students in the bisecting angle technique. Moreover, these simulations may also play a critical role in improving the procedural skills of not only dental hygienists but also other dental professionals. As such, VR simulations present significant potential as an effective educational tool for the advancement of radiographic skills and clinical competencies among dental hygiene students and can likewise serve as a valuable learning resource for other dental practitioners. To facilitate the integration of this technology into dental hygiene curricula, as well as the training programmes for other dental professionals, it is essential to develop and rigorously validate a variety of scenarios.
Author Contributions
Bogeun Lee and Sojung Mun contributed to conceptualisation, study design, methodology, data acquisition, data analysis and interpretation, project administration, supervision, validation, writing the original draft, review and editing. Hiejin Noh, Sunyoung Han, Jungyun Kang and Hanna Kim contributed to conceptualisation, study design, methodology and writing (review). Dajeong Lee contributed to assisting researchers in VR education.
Ethics Statement
This study was conducted after review and approval by the institutional review board of Yonsei University (1041849–202 208‐SB‐144‐02). All participants were given detailed verbal and written information regarding the purpose of the study, and written consent was obtained in accordance with the Declaration of Helsinki.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
This study received equipment and programme development support from VRAD, a company specialising in virtual reality medical education simulators.
Lee B., Mun S., Noh H., et al., “Effectiveness of Scenario‐Based Dental Hygiene Education Using Virtual Reality: Intraoral Radiography Training,” European Journal of Dental Education 30, no. 3 (2026): 842–852, 10.1111/eje.70039.
Funding: The authors received no specific funding for this work.
Data Availability Statement
Research data are not shared.
References
- 1. Grillon M. and Yeung A. W. K., “Content Analysis of YouTube Videos That Demonstrate Periapical Radiography,” Applied Sciences 12, no. 19 (2022): 9602. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Yeung A. W. K. and Wong N. S. M., “Medial Sigmoid Depression of the Mandibular Ramus as a Lesion‐Mimicking Anatomical Variation: A Systematic Review,” International Journal of Environmental Research and Public Health 18, no. 8 (2021): 4271. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Legislative Bureau , “Act on Medical Technologists, Etc.,” (2024), https://www.moleg.go.kr/.
- 4. Shin G. S., Kim Y. H., Lee B. R., et al., “The Actual State and the Utilization of Dental Radiography in Korea,” Journal of Radiological Science and Technology 33, no. 2 (2010): 109–120. [Google Scholar]
- 5. Yeung A. W. K. and Wong N. S. M., “Reject Rates of Radiographic Images in Dentomaxillofacial Radiology: A Literature Review,” International Journal of Environmental Research and Public Health 18 (2021): 8076. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Shetty A., Almeida F. T., Ganatra S., et al., “Evidence on Radiation Dose Reduction Using Rectangular Collimation: A Systematic Review,” International Dental Journal 69 (2019): 84–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Yeung A. W. K., Jacobs R., and Bornstein M. M., “Novel Low‐Dose Protocols Using Cone Beam Computed Tomography in Dental Medicine: A Review Focusing on Indications, Limitations, and Future Possibilities,” Clinical Oral Investigations 23 (2019): 2573–2581. [DOI] [PubMed] [Google Scholar]
- 8. Goren A. D., Lundeen R. C., S. T. Dealhl, 2nd , et al., “Updated Quality Assurance Self‐Assessment Exercise in Intraoral and Panoramic Radiography, American Academy of Oral and Maxillofacial Radiology, Radiology Practice Committee,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 89, no. 3 (2000): 369–374. [DOI] [PubMed] [Google Scholar]
- 9. Yen M. and Yeung A. W. K., “The Performance of Paralleling Technique and Bisecting Angle Technique for Taking Periapical Radiographs: A Systematic Review,” Dentistry Journal 11, no. 7 (2023): 155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Taguchi M., Wamasing P., Watanabe H., et al., “Applying the Paralleling Technique in Intraoral Periapical Radiographs for Japanese Patients by Analyzing CT Images,” Oral Radiology 37 (2021): 311–320. [DOI] [PubMed] [Google Scholar]
- 11. Korea Disease Control and Prevention Agency , “Annual Report on Personal Explosive Dose of Radiation‐Related Workers in Medical Institutions in 2022,” https://www.kdca.go.kr/.
- 12. Korea Foundation of Nuclear Safety , “Basic Radiation Safety Training for Radiation Workers,” (2019).
- 13. Gu J. Y. and Lee J. G., “Effects of a New Clinical Training Simulator for Dental Radiography Using Augmented Reality on Self‐Efficacy, Interest in Learning, Flow, and Practice Satisfaction,” Journal of Digital Contents Society 19, no. 9 (2018): 1811–1817. [Google Scholar]
- 14. Littlewood K. E., “High‐Fidelity Simulation as a Research Tool,” Best Practice & Research. Clinical Anaesthesiology 25, no. 4 (2011): 473–487. [DOI] [PubMed] [Google Scholar]
- 15. Morimoto T., Kobayashi T., Hirata H., et al., “XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis,” Journal of Clinical Medicine 11, no. 2 (2022): 470. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Monaghesh E., Negahdari R., and Samad‐Soltani T., “Application of Virtual Reality in Dental Implants: A Systematic Review,” BMC Oral Health 23, no. 1 (2023): 603. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Collaço E., Kira E., Sallaberry L. H., et al., “Immersion and Haptic Feedback Impacts on Dental Anesthesia Technical Skills Virtual Reality Training,” Journal of Dental Education 85, no. 4 (2021): 589–598. [DOI] [PubMed] [Google Scholar]
- 18. Im J. E., Gu J. Y., Lim E. J., and Lee J.‐G., “Virtual Reality Technology Using a 360° Video: Development and Evaluation of an Educational Tool for Intraoral Radiography Using the Bisecting Angle Technique,” Virtual Reality 27, no. 4 (2023): 3599–3612. [Google Scholar]
- 19. Cho H. E., “Attitude and Satisfaction of Head and Neck Anatomy Class Using Virtual Reality (VR) in Dental Hygiene Students,” Journal of the Korean Society of Dental Hygiene 21, no. 6 (2021): 813–820. [Google Scholar]
- 20. Lynn M. R., “Determination and Quantification of Content Validity,” Nursing Research 35, no. 6 (1986): 382–386. [PubMed] [Google Scholar]
- 21. Lee Y. H. and Ahn H. Y., “The Effects of Simulation Education for New Nurses on Emergency Management Using Low‐Fidelity Simulator,” Journal of Korean Academic Society of Nursing Education 25, no. 3 (2019): 331–343. [Google Scholar]
- 22. Salameh A. K. B., Malak M. Z., El‐Qirem F. A., et al., “Effect of Virtual Reality Simulation as a Teaching Strategy on Nursing Students' Satisfaction, Self‐Confidence, Performance, and Physiological Measures in Jordan,” Teaching and Learning in Nursing 19, no. 1 (2024): e235–e241. [Google Scholar]
- 23. Ahn G. S. and Kim H. J., “Analysis of Oral Radiography Practice,” Journal of Korean Society of Dental Hygiene 11, no. 5 (2011): 783–790. [Google Scholar]
- 24. Kim K. M., Kim Y. K., and Cho E. I., “A Comparative Study on Virtual Reality Simulation Program Education and Phantom Model Education on Oral Radiography Practice,” Journal of Korean Academy of Oral Health 18, no. 2 (2024): 141–148. [Google Scholar]
- 25. Nesenbergs K., Abolins V., Ormanis J., and Mednis A., “Use of Augmented and Virtual Reality in Remote Higher Education: A Systematic Umbrella Review,” Education in Science 11, no. 1 (2021): 8. [Google Scholar]
- 26. Choi H. W. and Choi Y. S., “Actual State of Dental Hygienist's Behavior for Infection Control During Dental Practice and Radiologic Examination,” Journal of the Korean Society of Dental Hygiene 11, no. 2 (2011): 169–178. [Google Scholar]
- 27. Nam Y. S., Yoo J. S., and Park M. S., “A Study on Actual Conditions for Prevention of Infections by Dental Hygienists,” Journal of Dental Hygiene Science 34, no. 2 (2010): 187–197. [Google Scholar]
- 28. Park J. H. and Jang K., “The Knowledge of Infection Control, Practice and Performance of Dental Hygienists,” Journal of Korean Society of Dental Hygiene 12, no. 5 (2012): 953–961. [Google Scholar]
- 29. Park J. T., Kim J. H., Kim M. Y., et al., “Effects of Educational Content for Dental Extraction Using Virtual Reality Technology on Dental Extraction Knowledge, Skill and Class Satisfaction,” Journal of Digital Contents Society 19, no. 2 (2019): 650–660. [Google Scholar]
- 30. Ismailoglu E. G. and Zaybak A., “Comparison of the Effectiveness of a Virtual Simulator With a Plastic Arm Model in Teaching Intravenous Catheter Insertion Skills,” Computers, Informatics, Nursing 36, no. 2 (2018): 98–105. [DOI] [PubMed] [Google Scholar]
- 31. Park S. Y. and Kim J. H., “Instructional Design and Educational Satisfaction for Virtual Environment Simulation in Undergraduate Nursing Education: The Mediating Effect of Learning Immersion,” BMC Medical Education 22, no. 1 (2022): 673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Lathrop A., Winningham B., and VandeVusse L., “Simulation‐Based Learning for Midwives: Background and Pilot Implementation,” Journal of Midwifery & Women's Health 52, no. 5 (2007): 492–498. [DOI] [PubMed] [Google Scholar]
- 33. Fowler L. P., “Improving Critical Thinking in Nursing Practice,” Journal for Nurses in Professional Development 14, no. 4 (1998): 183–187. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Research data are not shared.