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- Dentify : virtual reality and haptics in teaching dental implantology and operative dentistry: an approach to multimodal simulationPublication . Rodrigues, Pedro Miguel da Silva; Mendes, José João; Lopes, Daniel Simões; Ribeiro, Carlos ZagaloThe technological revolution is no longer imminent, but, instead, a reality. Technology has consolidated, in societies, the emergence of rapid change in the qualifications of the population and, consequently, the economy. In general, accessibility to information has expanded educational needs and demands. Particularly on the teaching and student population, the universalization of information technology has irreversibly imposed the appropriate pressure for the benefits of digital transformation and this, in turn, is directly dependent on the skill-set of its population. The real benefits of technological transformation can only be felt by a population, in the medium and long term, by placing these platforms in the integrated scheme of Education. The introduction of Virtual Reality (VR) and Haptic Technology (HT) have added new dimensions to education and the way we approach daily professional challenges. If, on the one hand, it is legitimate to say that necessity creates technology, on the other hand, it is equally valid to infer that technology imprints an irreversible need to reevaluate preexisting conventional methodologies, with an objectively critical and constructive sense. When applied to teaching, this strategy tends to provoke qualitative and quantitative changes on pedagogy with the purpose of improving the student. In Health teaching, its application has changed the approach paradigm to both the patient and the disease. It is unequivocally intended for a training process that is closer to the real thing and allows for a greater number of simulation repetitions prior to the medical act, to reduce the number of complications resulting from the act itself, enable greater predictability, and lower morbidity. Pre- and post-graduate education in Dentistry require an evolutionary break; a qualitative leap in line with the real technological potential that we currently have. More predictable results are desired from students with more training hours and with the constancy of competence that arises from repetition. This presents a real need and opportunity in Teaching. In dental training, the transition from preclinical pre- and post-graduate teaching to clinical teaching are moments of central importance for the student. It is in the preclinical stage that the student begins to develop the manual dexterity that will allow him/her to perform the fine and delicate movements and tactile perception necessary for the execution of the protocols inherent to treatment in such delicate tissues as oral tissues. It is also at this stage that the student is most likely to acquire the criteria of rigour and evaluation for the execution of such procedures. Traditionally, pre-clinical teaching occurs through simulation in synthetic and/or human or non-human non-living models, not considering patient motivation, expectations, pain and emergency situations that involve the treatments of real patients. Clear communication of the aforementioned evaluation criteria will allow the student to learn and define his own execution criteria, which is in line with the overarching goal of improving simulation to ease the transition to clinical life, thus reducing the anxiety associated with this transition as well as reducing iatrogenesis. Given the irreversibility of clinical protocols in Dentistry in general, and particularly in Operative Dentistry and Implantology, teaching in these areas presents, in the practical side of training, a fundamental vector in skill acquisition. The purpose of this research is to amplify Operative Dentistry and Dental Implantology teaching through the creation of a simulator with VR and haptic technology, centered on the student's self-assessment by exposing him/herself to simulated scenarios with virtual reality and haptic technology. Having identified the limitations inherent not only to conventional teaching in Implant Dentistry and Operative Dentistry, but also to available simulators, an immersive and multimodal simulator using virtual reality and haptic technology was developed, based on the student’s educational and pedagogical self-perception, allowing the transposition of the aforementioned limitations. The absence of universal evaluation systems, along with consistent simulation on artificial models with little pathological reality, distances conventional simulation from clinical reality. The project aims to validate the use of haptic technologies and virtual reality as methods to improve teaching in Dentistry and Implantology, with proven applicability in preclinical scenarios. The simulator could never be built without a collaborative strategy between pedagogy and programming. The contribution of educational sensitivity in Dentistry would first be introduced by testing the simulator prototype with experienced Dentistry professionals and professors at the Instituto Universitário Egas Moniz (IUEM), Egas Moniz School of Health and Science, in the areas of Dental Implantology and Operative Dentistry, in the context of collaborative work and co-design of the simulator. It was determined that tests with students would only take place after 1) validation of the prototypes through tests with professionals and their publication; and the introduction of changes suggested by the tests with professionals in a more definitive and elaborated version of the prototypes prior to testing with students. The development of the simulator was therefore subdivided into 2 vectors corresponding to the proposed areas: Dental Implantology (IMMPLANT) and Operative Dentistry (DENTIFY OD). IMMPLANT consists of a tech probe that combines a VR head-mounted display, a small hand tracking device placed in the front side of the VR headset and a smartphone, all connected to a laptop. User interaction with the virtual scenarios follows a bi-manual approach where the free (dominant) hand directly manipulates all 6 or 5 degrees-of-freedom of either the mandible or implant, respectively, while the other (non-dominant) hand operates a smartphone for more fine-tuned manipulation. DENTIFY OD is a multimodal simulator that resorts to VR and haptic pen technology. It places the student/user in an immersive virtual environment, composed of visual, auditory and haptic stimuli. It combines a haptic pen, VR goggles with audio output, turbine and drilling sounds, virtual dental models of isolated teeth and complete dental arches. To promote realism of the virtual environment immersion, the haptic pen grip has been replaced by a printed model of a dental turbine. It is intended to be a pedagogical tool for training and teaching the cavity preparation phase in OD, aimed at students in preclinical training for the purposes of improving the student's manual dexterity and three-dimensional spatial manipulation, increasing the number of repetitions per training session, and, additionally, providing a set of metrics corresponding to each use, per user. The simulator also allows for users to save their data per user and per simulation, thus allowing the user to compile a graphical progressive evaluation. Exposing the student to DENTIFY's metrics results aims to stimulate self-assessment and self-criticism, as well as the perception of the user's own learning curve on the grounds of objective and numerically measurable parameters. The tests performed by dental professionals with the IMMPLANT and DENTIFY OD prototypes were very encouraging to the progressive development of DENTIFY. Preliminary tests of IMMPLANT with professionals involved guided interviews, as well as usability and workload questionnaires, whose results allowed us to conclude that it constitutes a versatile virtual reality tool suitable for education in Dental Implantology. The co-design strategy mentioned above was extended to DENTIFY OD, using questionnaires on workload; cybersickness; system usability; and guided interviews. The user acceptance results allowed for the conclusion that DENTIFY OD shows potential in improving its teaching, promotes self-assessment, and provides a real multimodal immersion. It showed pedagogical potential in Operative Dentistry. Regarding of the Dental Implantology’s evolution, it was a conscious choice to not run the tests with students at this stage since, in development meetings, it was concluded that it was mandatory to explore more of its pedagogical potential, lest this tool be underutilized. Regarding DENTIFY OD, tests were performed with students on a renewed simulator, which included, in its reprogramming, results obtained from the previous tests, leading to software changes regarding its aesthetics, handling and usability. Tests with 3rd year Dental Medicine Integrated Master students at the IUEM took place in different sessions and focused on measuring self-assessment and usability by the users (undergraduates). Again, the results can be considered very positive. Students adhered very positively to sessions with the simulator, presenting indistinct performance metrics between users with and without previous experience with Virtual Reality, as well as similar results between gamers and non-gamers. The possibility of instant evaluation and, thus, helping in creating self-criticism in performance standards were considered fundamental in DENTIFY OD’s pedagogical attributes. The inherent potential of Virtual Reality and Haptic Technology suggests that these should be included in the pedagogical reality of pre-clinical teaching in Dentistry, in a definitive, gradual, and consistent manner while presenting measurable performance metrics that reflect the student’s evolutionary curve, numerically and without subjectivity. This work is in conformity with the following UNESCO Objectives for Sustainable Development: ODS 4 – Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all – by universalizing and allowing teaching by cost reduction of the available technology and, therefore, allowing accessibility. ODS 9 – to promote and foster innovation – by further enabling haptic technology and virtual reality in teaching Dental Medicine. To promote better oral health care services to the general community by improving dental teaching.