Design, Implementation and Evaluation of Educational Aid Game for Differential Diagnosis of Oral Lesions Through Mobile Learning

ABSTRACT

Introduction

The accurate recognition of oral lesions is a core competency in oral medicine. This skill is critical, as timely patient presentation is not always guaranteed, and precise diagnosis is essential, particularly for malignant lesions requiring immediate intervention to prevent serious health risks. Traditional learning can be reinforced through engaging methods that enhance interest and knowledge retention. This study aimed to develop a computer‐based educational game and evaluate its impact on student learning by comparing it with traditional instruction, while also assessing student attitudes towards mobile learning.

Materials and Methods

This interventional study involved 48 students from two dental schools, randomly allocated to an intervention group or a control group. A pretest established baseline knowledge. The intervention group used the educational game as a supplement to traditional teaching for 3 weeks, while the control group received only traditional instruction. A posttest was administered to both groups. Student attitudes towards mobile learning were evaluated in the intervention group using a validated questionnaire. Data were analysed using the Wilcoxon test for within‐group comparisons and the Mann–Whitney test for between‐group comparisons.

Results

Posttest scores increased from baseline in both groups. The within‐group improvement was statistically significant in the intervention group (p = 0.006) but not in the control group (p = 0.082). However, the between‐group difference in score improvement was not statistically significant (p = 0.312). Students in the intervention group reported positive attitudes towards mobile‐based learning.

Conclusion

The educational game showed potential in enhancing learning outcomes, with a significant improvement observed within the intervention group. Students expressed positive attitudes towards mobile‐based learning, valuing its accessibility and ability to diversify the learning experience. These findings suggest that game‐assisted mobile learning can serve as a valuable supplementary tool in dental education. Educators may consider integrating such tools to increase engagement and complement traditional teaching methods.

1. Introduction

Dentists must be knowledgeable not only in dental expertise but also in the normal structure and variations of tissues both inside and outside the oral cavity [1, 2, 3]. However, some normal variations may be misinterpreted as serious pathologies if not accurately recognized, potentially leading to unnecessary interventions and increased patient anxiety [4, 5, 6, 7]. Additionally, recognizing manifestations of systemic diseases is essential for establishing an accurate diagnosis and ensuring timely referral [8, 9]. Oral lesions constitute a fundamental component of the Dentistry and Oral Medicine curriculum, covering a broad spectrum of educational content [8, 9, 10, 11, 12].

Unfortunately, fragmented learning and confusion can arise in situations such as the COVID‐19 lockdown, where reduced patient availability leads to less effective and less structured clinical training [3, 13, 14, 15]. Prompt and accurate diagnosis and treatment planning are crucial, particularly for high‐risk conditions such as oral cancer, which require immediate and well‐coordinated management. Rapid and accurate diagnostic decision‐making is vital to prevent unnecessary risk to patients [16, 17, 18, 19].

Moreover, many oral lesions serve as early indicators of systemic diseases that require prompt referral [20, 21]. A dentist's diagnostic accuracy improves through continuous practice, critical review and staying updated with scientific evidence [7, 22]. One of the most effective strategies for retaining scientific information is the use of educational resources, structured assessments and visual materials, followed by periodic review [9]. Studies demonstrate that student‐centred teaching methods improve clinical performance and deepen learning compared with traditional, teacher‐centred approaches [9, 23, 24, 25]. As students become more actively engaged in the learning process, their critical thinking, communication abilities and teamwork skills are enhanced. Research also indicates that learning is more effective when the classroom environment is engaging and aligned with students' interests [6, 22].

Educational games can be designed to be user‐friendly and tailored to student preferences, thereby boosting motivation and improving learning outcomes. Such programs provide a rich, interactive learning experience in a cost‐effective manner, offering a safe environment for skill development and building self‐confidence without the fear of making mistakes that could harm patients [24, 26, 27]. In our view, the advantages of mobile learning include its accessibility, personalization, enjoy ability and potential to encourage creativity [23, 24, 26]. Mobile‐based learning represents a modern approach to accessing educational content through mobile devices, enabling learners to review material and engage actively. This can be accomplished using any smartphone, laptop, or tablet [24, 28, 29], ultimately enhancing learning effectiveness and promoting greater scientific competence [27]. Since learners often lack clinical experience, this method provides a low‐stress environment in which they can practice virtual diagnostic and clinical scenarios, thereby strengthening diagnostic abilities [9, 23]. Moreover, it can be used anytime and anywhere [22]. Technology and mobile applications further help students review course material, supporting the transition from short‐term to long‐term memory [24, 30]. The most important phenomenon now is the internetization of society and the penetration of digital technologies into the field of learning [31]. Demand for mobile learning in medical education is increasing [32].

To our knowledge, no dedicated educational game for dentistry currently exists in our country's market. Therefore, our objective was to design an educational game called “DahanBin” and implement it among a group of students while also evaluating their attitudes towards the game. The game aimed to develop both lower‐order thinking skills, such as recall and understanding, and higher‐order skills, such as application and analysis.

2. Materials and Methods

2.1. Study Design and Ethical Approval

An interventional study was conducted after obtaining ethical approval (code: IR.AJAUMS.REC.1401.114). The study involved general dentistry (DDS) students from the dental faculties of two universities: Tehran University of Medical Sciences and Aja University of Medical Sciences. All participants were in the internship phase and were invited to voluntarily use and evaluate a mobile‐based educational game. After receiving detailed information about the study, participants provided written informed consent and retained the right to decline participation at any time.

2.2. Development Team

The project was led by a team consisting of two oral medicine specialists, one medical education expert and a dental student.

2.3. Game Development Process

First, the team identified common oral lesions covered in the standard curriculum. To protect students' rights, the game was introduced as supplementary course material, and its use did not influence formal course assessment (Figure 1).

FIGURE 1.

The process of designing and research.

The “DAHANBIN” game was developed using textbook‐derived information on the common locations, clinical appearances, management approaches and differential diagnoses of oral lesions. For each lesion, a concise clinical scenario was created in line with these educational objectives. Key features of DAHANBIN include background music, timed questions, a scoring system, options to request extra time or view correct answers based on prior performance and the ability to replay questions with modified content.

The start menu consists of three sections: Main Menu, Game Guide and Training. Two difficulty levels—basic and advanced—were incorporated. Students could progress to the advanced level only after achieving adequate scores in all basic sections. The basic‐level content was drawn from earlier courses in the curriculum, while the advanced level corresponded to later coursework (Figures 2, 3, 4). Each question displayed the clinical appearance of a lesion and included an audio clip presenting a brief clinical scenario.

FIGURE 2.

The main menu of the program which includes a main menu that provides the entry code to the next step after successfully completing each step.

FIGURE 3.

A page from the basic stage of the game, which includes one of the four‐choice questions raised in the topic of recurrent aphthous stomatitis.

FIGURE 4.

A page from the advanced stage of the game, which includes one of the matching questions about the characteristics of the oral lesions including age, sex, clinical appearance, common location, and treatment.

The game design was comprehensive and visually structured, with all components—including sound effects—systematically outlined. An initial prototype was developed by an expert and pilot‐tested with a small student group. Feedback was collected to identify potential issues and areas for improvement, and the final version was refined accordingly. The completed game was installed on students' smartphones, and they were instructed to use it at least twice daily.

2.4. Study Participants and Randomization

Participants were randomly assigned to one of two groups (24 participants each) using a simple randomization method supported by a random‐number table. The control group received only the routine school curriculum, whereas the intervention group used the game in addition to the standard educational program (lectures and hands‐on training).

2.5. Assessment Instruments

Both groups completed a multiple‐choice pretest and posttest to evaluate knowledge of oral lesions. Students' attitudes were assessed using a validated questionnaire developed by Naderi et al. Although originally designed for paramedical students, its general and non‐specialised items made it suitable for the current sample. This 13‐item instrument uses a five‐point Likert scale ranging from strongly disagree (1) to strongly agree (5), with total scores ranging from 13 to 65. Scores below 20 indicate a negative attitude, scores between 21 and 45 indicate a neutral attitude and scores above 46 reflect a positive attitude. The reliability and validity of the questionnaire were previously established through factor analysis by Naderi et al. In this study, reliability was confirmed with a Cronbach's alpha of 0.90. The attitude questionnaire was administered as both a pretest and posttest only to the intervention group.

2.6. Data Analysis

Data were analysed using SPSS version 21 with descriptive and analytical statistics. Because the data were not normally distributed, the Wilcoxon test was used for within‐group comparisons, and the Mann–Whitney U test was applied for between‐group comparisons.

3. Result

Based on the findings of the present study, 48 students participated, comprising 12 females and 36 males—a distribution that mirrors the general gender ratio in dental education. In total, 50% of eligible students joined the study. The mean age in the control group was 25.46 (SD = 0.721), and in the intervention group, it was 25.29 (SD = 0.550). The youngest participant was 24 years old and the oldest was 27. All students were in their final internship year. Given that the general dentistry program lasts at least 6 years, students entering at age 18 would be at least 23 by their final year; those who started later or experienced academic delays were accordingly older. In terms of institutional distribution, 29 students were from Aja University of Medical Sciences and 19 were from Tehran University of Medical Sciences.

Although a gender imbalance existed between the two groups, this did not substantially influence baseline knowledge or interest in game‐based learning, as both groups included students with varying levels of interest. Nevertheless, greater gender balance would have been preferable. Importantly, baseline knowledge and academic levels were similar across both groups at the start of the study (Table 1).

TABLE 1.

Statistical calculations of age, gender and university variables.

Variable		Control group		Intervention group		p value
		Number	Percent	Number	Percent
Age	24	1	4.2	0	0	0.328
	25	13	54.2	18	75
	26	8	33.3	5	20.8
	27	2	8.3	1	4.2
University	Aja	15	62.5	14	58.3	0.768
	Tehran	9	37.5	10	41.7
Sex	Female	3	12.5	9	37.5	0.046
	Male	21	87.5	15	62.5

3.1. Learning Outcomes

The Wilcoxon test indicated a statistically significant improvement in learning scores within the intervention group (p = 0.006). However, the increase in mean learning scores within the control group was not significant (p = 0.082), and the between‐group difference assessed with the Mann–Whitney U test was also non‐significant (p = 0.312) (Figure 5).

FIGURE 5.

Graph of the difference between pretest and posttest of average student scores and their standard deviations (mean ± standard deviation).

3.2. Attitudes Towards Mobile Learning

The mean attitude score among students in the intervention group, measured using the instrument by Naderi et al., was 56.96 ± 5.28 (range: 47–65). According to the scoring criteria, scores below 20 reflect a negative attitude, scores of 21–45 a neutral attitude and scores above 46 a positive attitude. Since all participants scored above 46, the results indicate a consistently positive attitude towards mobile learning (Table 2). This suggests that the game successfully maintained student interest and engagement.

TABLE 2.

Interpretation of attitude questionnaire scores.

Score	Interpretation
Negative attitude	Less than 20
Neutral attitude	21–45
Positive attitude	More than 46

3.3. Coverage of Learning Objectives

The four main learning objectives of the study covering common lesion locations, treatments, clinical presentations and differential diagnoses were addressed through a comparable number of game questions, ensuring balanced attention to each educational domain.

4. Discussion

4.1. Learning in the Digital Era

Today, there is considerable criticism that traditional classrooms have changed little compared to a century ago. Meanwhile, the modern digital environment—computers, smartphones, video games and internet search engines—is reshaping cognitive processes. Millennials now constitute the majority of students in university settings. It is common for students to experience stress during theoretical or practical classes in labs or hospitals. In contrast, smartphone‐based education offers a non‐judgmental, low‐pressure environment where students can practice repeatedly without fear of making mistakes [33, 34].

4.2. Aligning Teaching Methods With New Generations

As dental and medical students, millennials often find conventional teaching methods frustrating. Mobile learning (m learning), especially when gamified, can engage Generation Z learners more effectively. However, designing an educational game for this demographic remains challenging [35]. The judicious use of technology can enhance trainer satisfaction. Our sample represented this generation, and with advances in programming, game design and smartphone penetration, capturing attention—particularly for educational games—has become increasingly difficult [36].

4.3. Impact on Learning Outcomes

Personal motivation for self‐study is crucial for student progress, a notion supported by the observed score increase in the control group through traditional teaching. In our study, posttest scores increased significantly in the intervention group (p = 0.006) but not in the control group (p = 0.082). Introducing enjoyment into teaching can yield benefits such as deeper learning, better retention and reduced stress among medical and dental students. The educational content and game questions were designed according to Bloom's taxonomy, targeting cognitive and affective domains. In this study, the educational content and game‐based questions were originally designed according to Bloom's taxonomy, aiming to cover cognitive and affective domains. However, it is important to clarify that our assessment method—based on multiple‐choice questions—primarily evaluates cognitive learning outcomes and partially reflects affective engagement through students' attitudes towards mobile learning. Due to the limitations of the MCQ format, real psychomotor skills could not be directly measured in this study, even though some questions were intended to engage students in clinical decision‐making processes related to psychomotor tasks. Therefore, the findings of this research indicate improvements in cognitive and affective domains, while no empirical evidence regarding psychomotor skill acquisition can be concluded.

4.4. Student Attitudes and Perceptions

The results revealed that students held positive attitudes towards mobile learning. This suggests that adopting such technology can offer significant educational advantages, potentially improving clinical confidence, theoretical knowledge and perceptions of mobile learning itself [35].

4.5. Between Group Comparisons and Limitations

Although both groups showed improvement, the difference in score gains between them was not statistically significant (p = 0.312). This lack of significance may be attributable to the relatively small sample size or the short intervention period, issues that could be addressed in future studies with larger cohorts and longer durations.

4.6. Gamification and Mobile Advantages

Previous research has reported that puzzle‐based educational games significantly enhance student learning [26]. Our study aligns with this finding, as we incorporated similar mechanics into our game. A key advantage of mobile applications over traditional puzzles is their greater accessibility, enabling more frequent and repeated use. Another strength of m learning is the ease of updating content, which is essential in fast‐evolving fields like dentistry and medicine. Furthermore, m learning offers diverse, engaging options seldom available in conventional teacher or learner‐centred classrooms.

4.7. Theoretical Foundations of Game Design

Several game features were intentionally aligned with educational theories to optimize learning. For example, immediate feedback after each task was incorporated to support formative assessment [37], allowing students to reflect in real time. Short, focused tasks were designed to minimize extraneous cognitive load [38], while gamified elements such as points and leader boards aimed to boost engagement and intrinsic motivation [39].

4.8. Adaptability and Replay Value

The game presents different questions across sessions, avoiding exact repetition. This variability helps maintain student interest and allows the game to be replayed multiple times with fresh content for each topic. Consequently, students can engage with the application repeatedly without monotony, supporting sustained learning [9].

4.9. Accessibility: Online and Offline Use

Although many useful mobile‐based educational games require internet access, our application functions both online and offline [9].

4.10. Safe Practice and Clinical Reasoning

Beyond the general benefits of m learning, students can practice clinical diagnosis in a stress‐free virtual environment. Virtual scenarios enable them to make errors and learn from consequences without jeopardizing patient safety [12]. Each case is structured to highlight key points, fostering organized thinking, critical analysis and improved decision‐making for treatment planning. The use of clinical photographs assists students in recognizing symptoms and understanding essential criteria for differential diagnosis.

4.11. Limitations and Future Directions

Some researchers have highlighted the value of 3D features in dental and medical applications; however, this version of our application does not yet include 3D visualization [40]. Despite study limitations such as the modest sample size and demographic imbalances, all participating students expressed interest in m learning and found the application useful and appealing. Access to concise clinical scenarios on a portable device facilitates rapid review of course material. Moreover, delivering educational content via a mobile app increases student motivation, and its ready availability remains a major advantage.

5. Conclusion

5.1. Main Findings

The findings of this study indicate that using a mobile application as a form of game‐based learning can promote student learning, as evidenced by the significant improvement in posttest scores within the intervention group. All participating students expressed a positive attitude towards using mobile phones for education (m learning). Based on their evaluations, they showed interest in educational software and games as a way to diversify learning methods and to facilitate easier access to educational materials beyond traditional classroom settings.

5.2. Implications for Teaching

Educators should consider adapting their teaching approaches to align with the preferences and needs of the digital generation. Given that smartphones are already integral to daily life, they represent a potent, underutilized tool for enhancing formal education.

5.3. Student Motivation and Engagement

Although intrinsic motivation was not directly measured with a dedicated scale, students' perceptions—such as increased willingness to engage with content and a preference for app‐based learning—serve as meaningful indirect indicators of enhanced motivation in the context of gamified education.

5.4. Overall Interpretation

Taken together, these results suggest that supplementing traditional teaching with well‐designed educational games can make learning more engaging and potentially more effective.

5.5. Recommendations and Future Research

It is recommended that more creative, technology‐enhanced methods be explored in dental and medical curricula. Future studies with larger, more demographically balanced samples and longer intervention periods are needed to confirm and extend these findings. Additionally, future research should employ assessment tools capable of directly measuring psychomotor skills—such as OSCEs or practical checklists—to complement the cognitive and affective outcomes captured by MCQ‐based tests.

Funding

The authors have nothing to report.

Ethics Statement

The present study was approved by the code of ethics, IR.AJAUMS.REC.1401.114 in Aja University of Medical Sciences, Tehran, Iran.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the funding of this study are available from the corresponding author upon reasonable request.