Gamifying Dental Anatomy Courses for Dental Hygiene Students

Gamifying Dental Anatomy Courses for Dental Hygiene Students

Andrew Nakhla

University of the Pacific, Arthur A. Dugoni School of Dentistry

EDUC-295P: Teaching and Assessment in Health Professions Education

Dr. Sinky Zheng

December 9, 2021
Gamifying Dental Anatomy Courses for Dental Hygiene Students

Introduction

Dental hygiene students take a course in dental anatomy during their first semester of

their program. The course aims to provide students with foundational knowledge of: dental

terminology, structures, anomalies, and treatment considerations for both permanent and primary

dentition. The majority of the course material is delivered through traditional instructional

methods, primarily via lectures in the classroom. Assessments are also done through traditional

methods such as periodic written or multiple-choice question quizzes and exams. Traditional

educational methods certainly work, but their limitations are highlighted when it comes to

courses which many perceive as “dry” or uninteresting. Due to the nature of the material, being

highly detailed and specific, students often have low motivation and engagement with the

information. When faced with an uninteresting topic delivered through uninteresting methods,

students will have difficulty engaging with the learning material and connecting it to the bigger

picture of “Why?” they need to learn it and how it relates to other areas of learning. Dental

anatomy is one of these topics where students often lack motivation to engage with the material

and find it uninteresting. Using a variety of technologies and strategies available now can

advance our delivery of information to engage new learners of the existing and future generation.

I plan to utilize the gaming tool, “Kahoot!” as a method for students to achieve greater learning

outcomes through a more active learning experience.

The redesign of this Dental Anatomy course aims to answer the following questions:

1. How effective are games at increasing student motivation and attitude towards

learning?
Gamifying Dental Anatomy Courses for Dental Hygiene Students

2. How does the implementation of a game during instruction increase student’s

retention of learning material?

Literature review

Current applications of serious games

The use of games in education has a growing adoption in schools in recent years. Serious

games are defined as “a game designed for a primary purpose other than pure entertainment.”

Zhonggen published a meta-analysis in 2019 evaluating the applications of serious games as an

educational tool. 729 publications were reviewed and filtered to determine the most relevant and

high quality data, leaving 39 publications used in the study. The study aimed to answer multiple

questions; The first subject being evaluated was the trend in the number of publications per year

over the course of 10 years from 2009 - 2018. The results show that publications and research on

the topic of serious games steadily increased year after year throughout the decade. This can

likely be attributed to the increasing use of, and interest in serious games in education. Factors

influencing the effect of serious game assisted learning was the second area being evaluated. The

results found that perceived usefulness, ease of use, and goal clarity were the primary indicators

in the effectiveness of serious game assisted learning (Zhonggen, 2019.) Keeping these factors in

mind when developing a game tool is crucial for its success.

Positive impacts of serious games on learning

Attitudes towards the use of a given technology has a significant impact on how well it's

received and adopted by its users. Attitudes towards serious games in learning was assessed in

the 2019 meta-analysis by Zhonggen. It was reported that “Learners held positive attitudes,

positive cognitive perceptions, and high positive and low negative affective perceptions

regarding various serious games assisted learning.” Learners generally had positive experiences
Gamifying Dental Anatomy Courses for Dental Hygiene Students

and attitudes towards, making it a promising addition and augmentation to the traditional

learning format. The author also notes that “serious games might encourage learners to hold

positive attitudes toward academic tasks with strong self-regulation if they were immersed in the

gaming situation.” This positive attitude will help to engage learners during their dental anatomy

studies and make the learning process more enjoyable.

The European Journal of Dental Education published a report in 2018 that while its exact

impact on knowledge retention may be unclear, it does make instruction more interesting and

engaging for students (K Sipiyaruk, J E Gallagher, S Hatzipanagos, P A Reynolds, 2018.) The

authors note that more research is needed to further explore the effects of games on knowledge

retention.

Game activities were implemented to aid in teaching anatomy of the liver and the portal

venous system to dental students. Student participants demonstrated a noted increase in their

exam scores following the games. (R Hill, Z Nassrallah, 2018.) The authors find that the use of

games in addition to lecture can serve as a helpful method to teach historically difficult subject

matter.

Various game formats and technologies are available to be used in an educational setting.

One consideration one may make when deciding which technology to use is whether the game

will have a competitive component to it. A 2021 review of eight publications posted in the

Morphologie journal found that “There is lack of evidence that the intensity of competition is

correlated with the educational outcomes and that game-based approaches motivate students to a

greater extent in comparison with other teaching methods.” (D Chytas, M Piagkou, K Natsis,

2021.)
Gamifying Dental Anatomy Courses for Dental Hygiene Students

Competitive gameplay was studied in a radiology course for medical students in 2020.

The online, 3-D, virtual world Second Life was used to create a competitive and engaging

learning environment in which students participated in multiple choice quizzes and online,

self-guided presentations; Student participants rated their experience on average an 8.1 on a

10-point scale. In addition to their positive experience, participants demonstrated a significant

improvement on future test scores over non-participants and left fewer questions on the exams

blank (R Lorenzo-Alvarez, T Rudolphi-Solero, M J Ruiz-Gomez, F Sendra-Portero, 2020.) The

combination of a positive user experience along with the active learning created by the

immersive gameplay further supports the use of digital based gameplay to augment traditional

lectures

The online game tool Kahoot was evaluated for its effectiveness in augmenting student

performance and engagement in a histology course taught at the University of Eastern Finland in

2019. A significant percentage of students reported a strong increase in their motivation to learn

and interest in the subject matter. Students also demonstrated increased performance in

overcoming difficulties (S Felszeghy, S Pasonen-Seppänen, A Koskela, P Nieminen, K

Härkönen, K M. A. Paldanius, S Gabbouj, K Ketola, M Hiltunen, M Lundin, T Haapaniemi, E

Sointu, E B Bauman, G E Gilbert, D Morton, A Mahonen, 2019.) This study highlights the

positive impact gamification can have on students' motivation, interest, and learning retention.

Using games during lecture can serve as a tool for formative assessment. In 2015, a study

was completed with medical students in their anatomy course. The students were grouped into

teams and competed in three rounds of the quiz-style game. Students rated their experience

positively; The majority of students reported in their surveys that the competition was engaging,

challenging, and they would participate again if given the opportunity. The students also reported
Gamifying Dental Anatomy Courses for Dental Hygiene Students

that they feel their knowledge of anatomy was enhanced and they were able to gain insight into

areas of strength and weakness. (A Janssen, T Shaw, P Goodyear, B P Kerfoot, D Bryce, 2015)

The added layer of team based play allows for student groups to discuss their knowledge,

creating opportunities for peer learning. It also can reduce individual anxiety when participating

in the game.

The COVID-19 pandemic required a sudden change in the delivery of lectures and

instructional material. Lectures became remote, often through Zoom; The lack of in-person

lectures and interactions prompted many educators to utilize other methods to engage their

students. The online game tool, Kahoot, reported a threefold increase in its usage following the

COVID-19 pandemic in 2020. Rebecca Donkin and Rosemary Rasmussen published a review of

existing literature on the use of game-based digital technology in 2021; The review included 12

studies from 2013 to 2020 and found “the majority of articles supported positive student

outcomes including improved collaborative learning, improved knowledge of content,

attendance, and participation.” (R Donkin, R Rasmussen, 2021.) Having game-based digital

technology can help adapt educators to meet the needs of different learning styles of students and

in various blended learning contexts.

Potential weaknesses and special considerations of serious games

The use of games in education can bring some drawbacks to consider. Using games too

often or inappropriately could serve as a hindrance to students' learning (Mehrotra, 2020.) A

2020 systematic review published in the Journal of Oral Biology and Craniofacial Research

reported that “A game is effective and efficient only when designed proficiently, leveled with

unambiguous rules and goals...” (Mehrotra, 2020.) Care must be taken when implementing
Gamifying Dental Anatomy Courses for Dental Hygiene Students

serious games in education. Done too frequently or without proper design, students can become

distracted by the game and fail to acquire new and relevant information from the activity.

Implementing games in education requires preparation. An investment of time and

thought is needed to effectively develop and use a game during instructional time; Due to the

limited time allotted for lecture and a busy schedule outside of the classroom, educators often

will opt for traditional instructional methods. (A C Pereira, A D Walmsley, 2019.) If time is not

permitting the educator to create a polished game design, then it may cause more confusion with

the students and distract them from the learning goals.

Some of the strengths of serious games are also some of its largest weaknesses:

variability and customization. Due to each individual game having to be set up and designed by

the instructor or a team, if certain design elements are not considered, it may fail to be as

effective or impactful on student learning as intended. A systematic review evaluating the

variables involved in the design of serious games was published in 2018. The design elements to

consider when developing a game include: avatars, badges for achievement, content unlocking,

difficulty adaptation, hints, leaderboard, performance, plot, points, teams, time pressure, and

virtual goods. (M Maheu-Cadotte, S Cossette, V Dubé, G Fontaine, T Mailhot, P Lavoie, A

Cournoyer, F Balli, and G Mathieu-Dupuis, 2018) The authors note that the optimal

implementation of each design element requires further research. Other studies have been

completed evaluating other aspects of the impact of design on the effectiveness of gameplay on

student learning. A 2010 systematic review published in the Journal of the Association of

American Medical Colleges found that interactivity, practice exercises, repetition, and feedback

are associated with improved learning outcomes (D A Cook, A J Levinson, S Garside, D M

Dupras, P J Erwin, V M Montori, 2010.) Considering these elements can help the instructor in

developing an effective serious game.

Methods

Study context & participants

This project will be completed at the University of the Pacific, Arthur A. Dugoni School

of Dentistry. Dugoni offers: a 3-year DDS program, along with multiple specialty options on

campus, an accelerated B.S. Dental Hygiene program, as well as other continuing education

certificates, licenses, and training.

This innovative redesign is planned to be implemented in January 2023 with first year

dental hygiene students during the first semester in their Dental Anatomy course. The total class

size is expected to be 20 students. Students in this course previous experience in dentistry

typically ranges from no prior experience to some dental assisting experience. Implementation of

Kahoot will begin from the first day of the course. Questions will be made and the quiz set-up

prior to lecture beginning. Students will remain anonymous to encourage participation and

reduce anxiety if they select the incorrect answer. Some sessions will also utilize team based

gameplay to introduce peer learning and discussion. Surveys for data collection will utilize

Google Forms.

Data collection

Data collection will begin at the start of the course. Before instruction begins on the first

session, a pre-course survey will be administered asking students to discuss their perceptions of

games used as a tool in lecture. This survey can be found in the appendix, Figure 1. This data

will be used as a baseline for students' perception and openness to using games in education.
Gamifying Dental Anatomy Courses for Dental Hygiene Students

First, the students will receive a demonstration of how to participate in a Kahoot game.

As a class, we will walk through step-by-step: joining a game through the game code, viewing

questions, and answering through their devices.

A no-stakes pre-course assessment quiz through Kahoot will be completed at the start of

lecture one. Information gained from students' performance will allow future lectures to be

adapted better to each class's unique dynamic. Students will complete this quiz anonymously and

individually.

Pre-lecture quizzes will be utilized at the start of each lecture to assess for retention of

knowledge from previous lectures All pre-lecture quizzes will be individual and anonymous to

each student; A random name generator will be used and assigned to students at each lecture.

These quizzes allow for spaced repetition of previous course material and serve as formative

assessment of their retention of learning. These will be low stakes with a low point value towards

final grade; grading will be based on performance in quizzes

Post-lecture quizzes will be utilized at the end of each lecture to assess for fulfillment of

learning objectives for a given session. These quizzes will be team based and will not be

anonymous. Students will team up in groups of 3-4. Students will share a single device and are

encouraged to discuss their answers and thoughts before making a selection. This provides

opportunities for peer teaching. Post-lecture quizzes will be no stakes; participation alone is

required. Their grade will be factored into total class participation grade

A post-survey will be completed at the end of the course asking students to elaborate on

their thoughts and experiences with Kahoot. For example, one question will ask students to rate

their satisfaction on a 10 point scale in four criteria: Making the material engaging/interesting,
Gamifying Dental Anatomy Courses for Dental Hygiene Students

motivating your learning in the material, retaining learning material, encouraging discussion and

learning among peers. The full post-course survey can be found in the appendix, Figure 2.0-2.1

Data analysis

Data will be analyzed through three methods. The first point of analysis is student

perception and experience. I will average student ratings on the 10 point scale in the post course

survey to understand student perceptions on engagement, motivation, and usefulness in learning

of Kahoot; This will answer question 1 of my research proposal.

The second point of analysis will be a measure of retained learning. I will average and

compare data from pre-lecture quiz scores with class average scores on midterm and final exams;

This will allow me to see the relation between performance on Kahoot games and scores on

summative assessments. Effectiveness of knowledge retention will be evaluated based on the

average number of students demonstrating passing grades in these quizzes as well as comparable

performance on exams. Greater than 25% of students failing in the quizzes or performing weakly

on exams compared to quizzes may represent a lack of retention.

The third and final point of analysis will measure the performance difference between the

test cohort and a control cohort which does not utilize game based learning. Midterm and final

exams of each cohort will be averaged and compared to determine if there is a correlation to

game based learning and improved exam performance. Point two and three of analysis answer

question 2 of my research proposal.

Kahoot will provide information in its data report on response frequency, scores, students

needing reteaching based on low performance, and difficult questions. This data, along with all

other data points from surveys and exam scores will be entered on a Google Sheet spreadsheet to

record and assist in analyzing and visualizing data.

Reflection

Kahoot can be accessed anywhere with an internet connection and with various devices,

including mobile phones. This flexibility allows for games to be developed anywhere by the

instructor; The ability to work on the games anywhere will be helpful as creation of each game

will require time investment. Kahoot can easily be made applicable to a blended learning

environment if the lecture requirement calls for it.

A challenge to consider when using this tool is that some students may not be as

technically savvy. To preempt this becoming an issue or challenge to students, I will create a

video tutorial walking students through the full step-by-step process of accessing the website,

answering questions or various formats, and completing the game. I will do a demo game with

the students in class to practice using Kahoot.

References

Chytas, D., Piagkou, M., & Natsis, K. (2021). Outcomes of the implementation of

game-based anatomy teaching approaches: An overview. Morphologie. Published.

https://doi.org/10.1016/j.morpho.2021.02.001

Cook, D. A., Hamstra, S. J., Brydges, R., Zendejas, B., Szostek, J. H., Wang, A.

T., Erwin, P. J., & Hatala, R. (2012). Comparative effectiveness of instructional design

features in simulation-based education: Systematic review and meta-analysis. Medical

Teacher, 35(1), e867–e898. https://doi.org/10.3109/0142159x.2012.714886

Donkin, R., & Rasmussen, R. (2021). Student Perception and the Effectiveness of

Kahoot!: A Scoping Review in Histology, Anatomy, and Medical Education. Anatomical

Sciences Education, 14(5), 572–585. https://doi.org/10.1002/ase.2094

Felszeghy, S., Pasonen-Seppänen, S., Koskela, A., Nieminen, P., Härkönen, K.,

Paldanius, K. M. A., Gabbouj, S., Ketola, K., Hiltunen, M., Lundin, M., Haapaniemi, T.,

Sointu, E., Bauman, E. B., Gilbert, G. E., Morton, D., & Mahonen, A. (2019). Using

online game-based platforms to improve student performance and engagement in

histology teaching. BMC Medical Education, 19(1).

https://doi.org/10.1186/s12909-019-1701-0

Hill, R. V., & Nassrallah, Z. (2018). A Game-Based Approach to Teaching and

Learning Anatomy of the Liver and Portal Venous System. MedEdPORTAL. Published.

https://doi.org/10.15766/mep_2374-8265.10696

Janssen, A., Shaw, T., Goodyear, P., Kerfoot, B. P., & Bryce, D. (2015). A little

healthy competition: using mixed methods to pilot a team-based digital game for boosting
Gamifying Dental Anatomy Courses for Dental Hygiene Students

medical student engagement with anatomy and histology content. BMC Medical

Education, 15(1). https://doi.org/10.1186/s12909-015-0455-6

Lorenzo‐Alvarez, R., Rudolphi‐Solero, T., Ruiz‐Gomez, M. J., &

Sendra‐Portero, F. (2019). Game‐Based Learning in Virtual Worlds: A Multiuser Online

Game for Medical Undergraduate Radiology Education within Second Life. Anatomical

Sciences Education, 13(5), 602–617. https://doi.org/10.1002/ase.1927

Maheu-Cadotte, M. A., Cossette, S., Dubé, V., Fontaine, G., Mailhot, T., Lavoie,

P., Cournoyer, A., Balli, F., & Mathieu-Dupuis, G. (2018). Effectiveness of serious games

and impact of design elements on engagement and educational outcomes in healthcare

professionals and students: a systematic review and meta-analysis protocol. BMJ Open,

8(3), e019871. https://doi.org/10.1136/bmjopen-2017-019871

Mehrotra, P. (2020). Edutainment in dental curriculum-A systematic review.

Journal of Oral Biology and Craniofacial Research, 10(4), 417–421.

https://doi.org/10.1016/j.jobcr.2020.07.016

Pereira, A. C., & Walmsley, A. D. (2019). Games in dental education: playing to

learn or learning to play? British Dental Journal, 227(6), 459–460.

https://doi.org/10.1038/s41415-019-0784-7

Sipiyaruk, K., Gallagher, J. E., Hatzipanagos, S., & Reynolds, P. A. (2018). A

rapid review of serious games: From healthcare education to dental education. European

Journal of Dental Education, 22(4), 243–257. https://doi.org/10.1111/eje.12338

Zhonggen, Y. (2019). A Meta-Analysis of Use of Serious Games in Education

over a Decade. International Journal of Computer Games Technology, 2019, 1–8.

https://doi.org/10.1155/2019/4797032
Gamifying Dental Anatomy Courses for Dental Hygiene Students

Appendix

Figure 1. Pre-course Google Forms survey

Figure 2.0 Post-course survey page 1

Figure 2.1 Post-course survey page 2