Journal of International Oral Health

REVIEW ARTICLES
Year
: 2021  |  Volume : 13  |  Issue : 3  |  Page : 201--206

COVID-19 and dental education: A Malaysian perspective


Mohamad Syahrizal Halim, Tahir Yusuf Noorani, Mohamad Isaqali Karobari, Noorshaida Kamaruddin 
 Conservative Dentistry Unit, School of Dental Science, Universiti Sains Malaysia, Kelantan, Malaysia

Correspondence Address:
Dr. Mohamad Syahrizal Halim
Conservative Dentistry Unit, School of Dental Science, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan.
Malaysia

Abstract

Dental education in Malaysia has been struck badly by the novel SARS-CoV2 coronavirus (COVID-19). This has brought to a halt all teaching and learning activities, aimed at stopping the spread of COVID-19, forcing students and lecturers to shift to online teaching and learning activities. However, dental education teaching and learning is unique in nature as it involves close contact with patients and aerosol-related procedures. This article discusses the challenges faced by the lecturers and students during this pandemic and offers some alternative strategies to bridge the gap in dental education during an unprecedented time. Although COVID-19 has ceased all clinical teaching and learning activities in most universities, it is imperative for the delivery of dental education to continue to ensure students are always engaged in learning activities. Although for many dental lecturers this change to online learning is a steep learning curve, they need to be fast learners, embrace the incorporation of technology into learning programs, and adapt to the new norms. They need to familiarize themselves with online learning to ensure that the course syllabus is covered comprehensively. For students, they must have the right mindset that this change is bound to exist until COVID-19 has been brought under control and lockdown is no more relevant.



How to cite this article:
Halim MS, Noorani TY, Karobari MI, Kamaruddin N. COVID-19 and dental education: A Malaysian perspective.J Int Oral Health 2021;13:201-206


How to cite this URL:
Halim MS, Noorani TY, Karobari MI, Kamaruddin N. COVID-19 and dental education: A Malaysian perspective. J Int Oral Health [serial online] 2021 [cited 2021 Jul 27 ];13:201-206
Available from: https://www.jioh.org/text.asp?2021/13/3/201/318459


Full Text

 Introduction



Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or better known as coronavirus disease 2019 (COVID-19) infection is caused by the novel coronaviridae virus, originating from Wuhan Province, China. This has led to a global COVID-19 pandemic,[1] forcing universities to close their operations, thus sending students back to their homes or locked down in their hostels. Hospitals suspended all nonessential services, including dental procedures, only to cater for emergency procedures.

Although in the last two decades alone, there have been two cases of coronaviridae virus outbreak, Severe Acute Respiratory Syndrome (SARS) in 2002 and Middle East Respiratory Syndrome (MERS) in 2004, coronavirus has still become an issue that cannot be contained. Special attention should be given to dentistry as coronavirus tends to infect the human lungs and is transmitted via aerosol and droplets. This respiratory virus outbreak has affected many sectors, particularly education and dentistry, which is the prime interest of this article. The repercussions of the pandemic towards dental or medical education have not been fully studied except in Hong Kong,[2] China,[3] and South Korea.[4] Patil et al. advocates the restriction of mass gathering of medical students in a lecture hall. The use of information technology into teaching and learning was encouraged.[2] This was further highlighted by Meng et al., where they recommend adopting to online lectures, case studies, and problem-based learning during outbreak in China. Students are also encouraged to take part in self-improving themselves by self-directed learning.[3] Park et al. suggested more detail measures to ensure protection to medical students by advocating the discontinuation of bedside case clerking, self monitoring of health status, closure of the medical school and adjusting the academic calendar in affected teaching hospital, arranging schedule patient clerking at another teaching hospital, and remote lectures and problem-based learning tutorials.

The COVID-19 pandemic has disrupted many normal daily activities all around the world, including dental education. Schools and universities across the globe have suspended face-to-face teaching, learning activities and are encouraged to resume lectures via online platform to curb the spread of COVID-19.[1] Social gatherings, including those in educational institutions, are banned due to the threat of promoting the spread of COVID-19. Some students were sent back to their hometown until further notice. This is the scenario that was faced by the Malaysian dental universities students when the government imposed a strict Movement Control Order (MCO) from 18 March to 17 May 2021, where all face-to-face teaching and learning was halted.[5] Then on 27 April 2020, the Malaysian Higher Education Ministry started the process of sending most of the universities student to their hometown. All teaching and learning activities needs to be continued via online distant learning including dental students until 31 December 2020.[6] This has caught many students and educators off guard with a drastic transition to distant online teaching and learning (e-learning) to ensure students are not left idle during this pandemic lockdown. Even though we are already in the digital era, most students are still comfortable with conventional didactic lectures and face-to-face teaching and learning activities, while they cope with online learning.[7] This was made more difficult as the directive and information from the Government keep changing from time to time due to different phases of MCO in Malaysia.[8] There was a time when that face-to-face teaching and learning was allowed to be done with minimal attendance especially among students that need practical session and final year students after the CMCO was implemented.[9],[10] But sudden spike in cases in Malaysia led to a 2nd MCO which again halted face-to-face teaching and learning.[11] This setback imposed stress to students, lecturers, and administrators.

Dentistry has been categorized as a very-high risk occupation for potential COVID-19 infection spread.[12] This is due to the aerosol generating procedures associated commonly with all patient treatments.[7] Dentistry deals with the oral cavity of a patient which harbors millions of bacteria and viruses. Furthermore, aerosols are created when dental personnel use high speed hand pieces and ultrasonic scalers in a patients’ mouth. This leads to easier transmission of airborne diseases, particularly the COVID-19 virus in dental clinics, potentially affecting the dental practitioner, assisting staff and the patient themselves. Thus, the nature of dentistry makes it even more challenging in delivering dental education during the COVID-19 pandemic. The balance between protection of dental students, staffs, and patients while fulfilling the requirements of nurturing a competent future dentist is difficult. Social distancing in practising dentistry is almost impossible. A dentist needs to be trained with adequate knowledge together with good clinical skills to be competent during undergraduate training. Dental education is designed to cover specific cognitive (knowledge) and psychomotor aspects (skills) to equip dental students in treating patients effectively. These skills cannot be taught through a video demonstration alone; it requires a certified tutor or lecturer to show and guide them to be competent in certain procedures. Students need to be taught on the responsibility of treating patients, following the standard operating protocol for specific clinical procedures and observation of chairside etiquettes in dealing with patients complaint and problems. This is necessary especially in Malaysia because every dental school is checked regularly by a governing body, that is the Malaysian Qualifying Agency (MQA) and every dental school is obliged to adhere to the criteria and requirements that have been set by them. Many dental schools in Malaysia still uphold the minimum clinical experiences together with a competency-based assessment in every discipline before a student can graduate as a competent dentist.

What We Already Know

COVID-19 is affecting every sector of daily life.

COVID-19 has left the educational sector with uncertainty future and instability.

Dentistry is at high risk of spreading the COVID-19 disease

What this Article Adds

Insight of dental students perspective towards COVID-19 pandemic to their routine academic activites.

Dental educators perspective towards online distance learning in dentistry and the repercussions towards resulting dental education standards.

The aim of this article is to provide an insight on the challenges faced by the dental education system and contains recommendations to dental schools and faculties on alternative to fulfill the expected requirements to nurture and help competent dental graduates.

 Students’ Perspective



Tuition fees

There are two types of dental colleges in Malaysia currently, one being government funded universities and the other is private universities. The former has minimal fees ranging between MYR 14,000 and the later may reach up to MYR 600,000 for 5 years course.[13] The impact of this COVID-19 on students in public or government universities may not be as hard as that of private institute dental students. Nonetheless, students are still expected to pay their fees in full, regardless of the class being postponed and halted due to this pandemic. Online classes are still conducted, but without practical or clinical session.

This leads to students’ acceptance towards online learning beyond satisfactory. The online classes did not seem equivalent to the amount of money they invested in the tuition fees. They hoped online learning will not resume after the pandemic is under control and the movement control order (MCO) ends.[7] Some of them hoped they can get reimbursed for their missed classes and clinical sessions. But this is unlikely as the university has invested a lot of money in human resources, equipment, and facilities to ensure the classes can resume online and students were not left idle during COVID-19 associated MCO. This requires a forbearance from both sides.

Many students also feel overburdened with the current COVID-19 pandemic. They are not allowed to go to classes, meet their peers and lecturers. Pre-clinical practical sessions cannot be done at the university and clinical students cannot see patients. Some students who are sponsored candidates feel stressed because they are tied to a fixed timeline given by their sponsors to finish their study. With MCO or lockdown, they cannot complete their clinical requirements. Hence they cannot fulfill the necessary requirements to appear for the final exams. Students’ sponsors need to be aware of the unforeseen circumstances faced by the students under their sponsorship during these unprecedented times.

Some self-sponsored students have also had a difficulty in paying their tuition fees. This may be because their parents or guardian were laid off due to the recession and slowdown in most economic sectors. The universities need to be mindful of this condition and work out some easy payment scheme or direct the students to financial aid to ensure the continuity of education for these affected students.

Peer connection

Peer connection is very important as an informal teaching and learning process. Exchange of ideas and revision of individual understanding of certain topics might vary. Hence they need to get in touch with their peers. Meeting and discussion with peers during seminars, problem-based learning (PBL) activities, case-based learning (CBL), and tutorials will enhance their critical thinking towards problem-solving. Face-to-face communication during seminars will boost their confidence in talking to a colleague, lecturers, and patients. Good communication skills are very crucial to extract information from the patient regarding their disease or problem, developing a diagnosis, and formulating a treatment plan. This platform is useful in case of introvert students since they must face a tutor or lecturer in the seminar, CBL, or PBL session.

Without doubt this can also be done through online or distant learning as was undertaken in School of Medical Sciences Universiti Sains Malaysia;[8] however, the experience may not be the same. Students may lose focus and motivation since it is proven that increased screen time may deviate students’ attention.[9] Additionally, the environment the students face at home may also deter them from focusing on the online classes. Distraction from siblings, parents, improper place to study may result in loss of focus. The absence of social interaction and formation of study groups are some of the drawbacks of online learning. Lecturers cannot sense students’ incomprehension through facial expression, change in the mood by small jokes in between the tutorial, and absence of students engagement and interaction are some of the drawbacks of online learning.[7]

Internet connection for online learning

To have suitable online classes, lecturers and students need to have a very good and stable internet connection together with sound technical computer skills.[10] These are one of the major issues being faced by both parties during distant online learning.[11],[12] This is worrying because 60% of the students did their online learning from their home which is in town or city areas with only 6% of students have a very good internet connection and 40% with good internet connectivity.[7] Not to mention some lecturers are also not familiar with this new norm during COVID-19 pandemic. Since most university students, including dental students were sent home by their respective universities during the MCO imposed by the Government of Malaysia, the internet connection was a major setback. In Malaysia, there are areas still without good internet coverage. This will affect some students and their learning experience, especially those from rural areas. Even though internet is easily accessible in most places in Malaysia, the stability of the internet connection was not good during MCO time. A sudden increase in internet traffic shocked most internet providers in Malaysia, forcing them to improve their service.

This issue may be tackled by increasing the asynchronous rather than synchronous online learning. Lecturers can record a video presentation, edit, and upload their lecture content in specific online learning platforms for their students to revise. This is very useful where students can go to a specific place such as near the main road in rural areas to download the video content shared by their lecturer. This method is suitable when two-way communication is not necessary for the learning outcome of that specific topic. This way, students can use their internet data cautiously, when compared with synchronous teaching and learning activities which uses big internet data. This also is a challenge to telecommunication carriers to widen their coverage and improve the stability of internet connection. Not every student has the luxury of having a fixed home broadband, most of them rely on mobile internet which can sometime become unstable especially in rural areas or when there is an increase in internet traffic at specific point of time such as during the MCO.

Lack of student’s engagement during online classes

Some students are reluctant and resilient towards online classes. This may be due to individual preferences and attitudes. They prefer online learning to be a supplemental form to conventional classes, in the form of flash lectures and procedural videos.[13]

This can be improved by introducing online learning to the students at the very beginning of dental school enrolment, expectations of distant learning made clear to each student including explaining to them in the course or module description. Extra points for continuous assessment can be given for students’ participation during online seminar, case-based discussion or journal club, whether synchronous or asynchronous classes. This requires the creativity of dental lecturers to encourage students to participate in online classes.

Quality of online learning activity materials

Online learning has shown to save time, reduce cost, allowing students to learn in their flexible time outside the classroom and with broader knowledge transfer. This methods also allows a shift towards more active learner centered rather than passive teacher centered learning.[14],[15] But to ensure the success of online learning, student satisfaction is one of the key factors.[16] This can be fulfilled by ensuring the contents of the online lecture is interactive, with the intended learning outcomes being coverage and ease of access.[17] Lecturers need to ensure they have this expertise in online teaching and this challenge should be accepted with open arms. Students need to be offered a valuable and interactive online learning activities to ensure their acceptance and readiness to change. This is important to avoid the withdrawal from online learning activities and shift towards traditional face-to-face teaching and learning activities in the future once face-to-face learning activities is resume.[7]

Practical-based competencies

Competency refers to the expected qualification of an individual who is about to begin an independent practice of a profession with specific skills, knowledge, and values expected in that profession. Most dental schools in Malaysia adhere to competency-based exams, requiring students to be assessed by lecturers while treating patients. Competency-based procedure cannot be taught or examined via online learning. Since conventional chairside teaching is forbidden during MCO, practical-based subjects are lacking in exercise including communication skills with patients. Students’ self-perceived competency also may also be affected because of inadequate credit hours in practical session including chairside clinical teaching. Most dental students are taught to treat a patient’s problem, not just by observing. They need to learn how to communicate with the patient during history taking, know and feel how to do a correct restoration, correct way to extract a tooth or proper way to do a crown preparation. This cannot be achieved by online learning alone. A tutor or lecturer needs to be at their side to ensure the proper procedure being conducted, be able to correct the students’ mistakes together with ensuring the patients’ safety throughout the dental procedure.

Although it has been suggested that the solution to this is to have peer reviews of the students clinical work together with a panel of supervising faculty member, this is still not very convincing.[18] One suggestion would be to delay the academic year until COVID-19 cases can be brought to a controllable number or until a vaccine is made available. This may result in many students and university authorities being unhappy since the students cannot achieve graduation on time. This will be unpopular but a necessary sacrifice during unprecedented COVID-19 pandemic. Maybe this is the time where universities, faculty, and regulatory agencies to be more flexible regarding curriculum fulfillments and competency assessment. This has to be taken into account as the students also face pandemic-related and financial stress.[16] Up to date, there was no official press release from Malaysia Dental Dean Cauncil regarding this requirement for undergraduate students to graduate, but nonetheless this issue has been sorted out internally.

 Academia Perspective



Online learning skills and competencies

It has been brought to attention that it is important to systematically plan and train lecturers on online teaching in medical education as well as dental education.[19] Firstly, as an academician cum clinical specialist in each discipline, lecturers need to have good understanding on different types of pedagogies in online teaching. Synchronous teaching is a real-time interaction between a lecturer and the students, whereas asynchronous teaching is a pre-recorded video or slides before or after the classes begin.[20] These different teaching methods serve its own purposes. Synchronous teaching aims to fulfill knowledge delivery to a novice and encourage peer interaction like a classroom setting. Didactic lectures can be delivered to students, supported by online seminars to encourage students to discuss on issues related to the topic. By this method, lecturers can engage actively with the students, grade the students during online classes and show a demo on certain clinical procedures. Critical thinking can be assessed during synchronous teaching, but limited to one person discussion at one time to ensure proper delivery of messages and input. This synchronous teaching can be done with various video webinar platforms such as Microsoft TEAMS, WEBEX, Zoom, Skype, or Whatsapp.

Asynchronous teaching involves preparing a lecture material and uploading it to the institutional e-learning platform to be accessed at the students’ convenience. This will facilitate collaborative learning and ensure effective embedded knowledge to the students. In this method, students are encouraged to seek out of classroom knowledge, videos, and tutorials to ensure they observe the clinical procedures before they do it on live patients. But with this, sometimes the information from the internet can be overwhelming and irrelevant to students expected programme outcome. The videos and tutorials from the web may not be the standard operating procedure from the universities, which makes it dangerous for students to practice.

During this difficult time, it is necessary for lecturers to keep themselves updated with the current trends and knowledge especially in online learning skills to get the attention from the students. It is not an easy change, but a change that must be done although it has resulted in substantial adjustment. The Ministry of Higher Education of Malaysia has been promoting the usage of online e-learning platform to deliver the course teaching material. Preclinical lectures and case-based exercise can be delivered using a video recording followed by an online quiz. Clinical video related to certain topics can be shared from the internet source if not readily available at the lecturers’ disposal. This is necessary to keep students engaged during lockdown or MCO.[21]

Assessment for cognitive (knowledge), psychomotor (skills), and affective domain

During the lockdown or MCO, dental students are not allowed to be in campus. Examinations can be difficult to be conducted if MCO or lockdown is extended. Although theory exams in the form of Multiple choice Question (MCQs), Short answer question (SAQs), and clinical scenario with photos for objective structure clinical examination (OSCE) can be done via e-learning platform, the psychomotor assessment for clinical examination still cannot be undertaken. Lecturers may not be able to assess students’ performance for psychomotor domain or clinical skills aspects during this MCO. This is very disturbing as dentistry deals a lot with clinical skills together with affective domain or professionalism aspect. A suggestion was to have the psychomotor assessment at a later date once the MCO is lifted and results from current examination considered provisional until subsequent psychomotor component examinations were done.[8] This may be suitable in other years of the dentistry program but not the final year; because they are going to be registered as qualified dental practitioners once final exam results are announced. Alternatively, dental schools can opt for alternative competency examinations during final year professional exam that does not involve direct patient contact such as procedures on typodont teeth in the pre-clinical laboratory. Dental schools can also consider a more longitudinal and global assessment of students overall competence rather than a single point during final professional examination.[22]

Research activities and publication

Since many dental schools closed their operations when the government imposed a lockdown or MCO, laboratory research-based activities were also put on hold. Any ongoing laboratory procedures and some time-sensitive specimens were damaged when researchers could not go to the laboratory. Most researchers that are involved in a laboratory-based study are either financed by a local or international grant and are in a rigid time line, where their research needs to be finished before the due date, not to mention the report of findings from the research activities. No doubt this made many researchers sleepless and distressed. The sponsoring body needs to be aware of this unprecedented COVID-19 pandemic lockdown which forces every activity to be put on hold. Indeed, they should be able to negotiate their contract regarding the timeline to finish their research project.

During COVID-19 pandemic, there were some silver linings observed. Since many researchers were forced to stay at home, pending manuscripts could be completed resulting in a sudden surge of publication submissions to various journals.[17],[18],[19] This has forced journal editors to really scrutinize the research papers with more caution for their respective journals. Three months after the lockdown, it was far more difficult to publish an article due to this increase in submissions for publication according to various authors’ experience.

 Conclusion



Although COVID-19 has ceased all clinical teaching and learning activities in most universities, it is imperative for delivery of dental education to continue to ensure students are always engaged in learning activities.[23] Although for many dental lecturers this change to online learning is a steep learning curve, they need to be fast learners, embrace the incorporation of technology into learning programs, and adapt to the new norms. They need to familiarize themselves with online learning to ensure that the course syllabus is covered comprehensively. For students, they must have the right mind set that this change is bound to exist until COVID-19 has been brought under control and MCO or lockdown is no more relevant.

Recommendation

Future respiratory disease outbreak is difficult to predict as this depends so much on the ability of certain virus strains to mutate and causing severe manifestation in human once it cross-infects from animals. Therefore, it is paramount to all dental schools to equip themselves with the equipment and facilities to continuously cater treatment to patients even during the pandemic. It has been acknowledged that dental treatment is highly potential for the spread of airborne disease, hence there is no reason for dental school to not be prepared for future outbreak to ensure the ongoing dental treatment and dental education during the outbreak. Every dental school should allocate an area for highly infectious disease treatment delivery for at least 30% from their allocated dental chair.

Acknowledgement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

Authors declare there are no conflict of interest.

Author contributions

MH and MK: Final draft and conceptualization; MH,TN, MK: First draft, revision, and final approval; MK,NK: Revision and plagiarism check; MH,MK,NK: Article writing and first draft; MK: Advisor, first draft, revision, and final approval; TN,NK: Advisor, first draft, and revision. Finally, all authors approved the final version of the manuscript for publication.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

Not applicable.

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