Digital Dental Technology: Not just CAD/CAM

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Dental technology is quite a unique discipline to teach. At the end of study, graduates should be employable, capable practitioners and in the eyes of the General Dental Council, ‘safe beginners’. Like any other business, universities and colleges are not bottomless pits of money yet need constant investment to keep up with changing trends and the latest materials. CAD/CAM has recently been installed at MMU in response to the near total domination of industry trade shows and uptake by labs. It’s not the next big thing; it’s the ’now big thing’ and is unlikely to diminish. However, stories are abound of labs employing computer savvy people to operate the software, only to find some time later that, for example, ceramic is shearing off the substrate due to insufficient support for it. CAD/CAM is a prime example of where the operator needs an education (and ideally some experience) in the principles of manufacture and the limitations of materials when placed in the oral environment. I recently watched a YouTube video of the patterning stage of a CAD/CAM removable partial denture framework and noticed many errors made by the operator. They showed little knowledge of planning a device for long-term use. Nowhere did they attempt to consider the effects of relining at a later date or the way in which bone resorbs at the tuberosities. Despite being the latest technology, the same mistakes were still made. Like any tool, it takes knowledge and experience to master it.

Matthew Syed’s book ‘Bounce’ explores the science of success and the underlying theme is that it takes about 10,000 hours to master a complex task (Syed, 2011). It’s not just the learning, but the repeated experience and environment that hone skills to a point of mastery. By way of an illustration, Desmond Douglas was one of the UK’s most famous table tennis players. He had quicker reactions than anyone else, yet examination of his technique revealed that he had slowest responses than the entire England squad (including the manager!) when measured in a laboratory test. On closer examination, it was found that his learning environment was a major factor in the development of his ability. When he practiced in his early days, there was very little room between the table edge and the wall of the building. Consequently he had to stand closer to the table and just learned to take the shots sooner than others.

Similarly, in the right environment, a dental technology graduate who is allowed to develop through task repetition; with gradually increasing complexity will, over time develop into a valuable laboratory team member. It must be remembered here how much this young person has already invested in their career in dental technology. A three-year course, in fees alone will typically set them back in the region of £27000. Add on accommodation and living fees and it is a massive investment. This is a person who has committed himself or herself to a particular niche area of healthcare in the UK.

CAD/CAM is an example of how digital technologies have taken over many stages of manufacture in dental technology. This does not sit comfortably with those trained and experienced with the lost wax technique and who hold a candle to traditions and crafts that are, in their eyes, at the heart of dental technology. However, the ’CAM’ part of the acronym has little educational value. A student does not learn much by watching a milling machine execute the commands generated from an STL file. A laboratory invests in CAD/CAM to improve yield and quality and ultimately make money. In an educational setting, the CAD/CAM system does not make money and therefore has to be justified as expenditure. The real value in an educational setting is that it helps students to understand the key concepts of restoration design, morphology and occlusion and most importantly of all, allows them to make mistakes they can learn from. Henry Ford always said he learned nothing from his successes, only from his failures. Simulated cases on a screen allow “what if?” questions to be asked.

“The digital revolution marches on”

The way students learn varies enormously. Some are visual learners, some are experiential. The author of “Hitchhikers Guide to the Galaxy”, Douglas Adams once quoted “whatever’s in the world when you’re born is just normal”. Today’s teenagers have grown up with technology and it’s just a normal part of their lives. They work and play on their mobile devices and it’s here too that the digital revolution marches on.

Educational institutions are already playing catch-up to reach students through their mobile devices and to break the Victorian classroom setting where a lecturer stands in front of rows of desks. ESSA Academy near Bolton was a bold experiment in the adoption of a completely different approach to learning where teachers and pupils share learning and social spaces. There are no staff offices, no segregation and very few books. Every pupil and every member of staff owns a school-issued iPad that they can also take home (to do homework on). The obvious reaction here is “Well how much does all that cost?” but before you do, consider the cost of individual PC’s, software licenses for those PC’s, Ethernet cabling, maintenance, applications, power consumption and the physical space where they reside that cannot be used for anything else. ESSA Academy has not merely dipped their toes into this new approach to learning; they have jumped from the pier. They are also not alone.

The ‘Flipped Classroom’

Across the globe, a new style of learning and teaching is gathering momentum, the ‘Flipped Classroom’. In its simplest terms, the students do their schoolwork at home and their homework at school. In a normal (un-flipped) session, this would constitute a teacher spending an hour or so explaining facts, figures, principles and methods to a group of students then they would be given homework to put these methods and principles into practice. However, when the students need their teacher the most, when working on the problems, they are unavailable. In the Flipped scenario, the students watch videos and learn the basic principles online at home, in their own time, at their own pace and as many times as they need. When they come into the session, they work on problems associated with the principles and methods and have their teacher available to assist them should they need them.

Dental technology is ideally suited to the Flipped Classroom scenario. Dental devices are typically made in a sequence of procedures that can be split up into separate stages; each of which can be delivered in order so that the user (student) may learn in advance of a particular laboratory session as part of a course. When I studied dental technology, I learned by watching a live demonstration by a lecturer. This meant that I had one chance to see it and could not access it again, either in or away from college. At the time however, this did not occur to me as poor practice as it was just normal for my particular time. My class consisted of only 16 students and we all had a view that was good in places and merely acceptable in others. The quality of the learning experience was directly proportional to the proximity to the demonstration and, crying out for a better solution.

Embracing new technology

When early digital video became popular, educators embraced the technology and developed visual learning resources, which were first distributed via DVD and later by a rather limited, infantile Internet. Of course, connection speeds increased but a desktop or laptop PC with a wired connection was still required to access content at a suitable quality. It was as though a major part was still missing from the jigsaw. Another Douglas Adams quote summed it up, “technology could be defined as ’stuff that doesn’t work yet’”. Indeed, aided by a British Telecom grant, MMU even developed and published ’dentalTec’ which was an early ’YouTube’ which had the video content and authoring environment but sadly no way to deliver it to anyone. Video clips were limited to a mere 15 seconds. Any longer than that and a cup of tea could be made whilst waiting for it to download. Streaming was still a way off.

On January 9th 2007, Steve Jobs took to the stage at the Moscone Centre in San Francisco, turned the mobile phone industry upside-down and casually dropped that missing piece into the jigsaw. Technologically, it was the aligning of the planets. No longer were people tied to the desktop and the mobile Internet was given the boost it had been waiting for. Jobs never planned for third party Apps as he had no way to police their quality but a year later, under mounting pressure from Apple board member Art Levinson, he relented and set up the ecosystem that sees Apple take a 30% cut of everything (Dredge, 2011). It is of note here that the word “App” has only existed since 2008 and is now potentially a 20+ billion dollar a year industry (Lessin and Ante, 2013; Jones, 2013).

With this in mind and the way in which dental technology was taught inspired me to develop and App for the iPhone that would allow students to watch demonstrations of coursework stages as many times as they wanted, wherever they wanted. I had an advantage, as I had been a coder in the 80’s, writing video games for the ZX Spectrum. True to the saying, “necessity really is the mother of all invention”, the App addressed the problem of allowing everyone a good view, anywhere and anytime. Released on September 10th 2012, the App named ‘RPD Online’ is now on version 3 and has over a thousand downloads worldwide, on all continents. Agreed, it’s not exactly ‘Angry Birds’ but for what is a rather niche area, an acceptable uptake. Of course, not every student has an iPhone but a survey at MMU found that 98% of students had a mobile phone, the significant majority of which were smartphones. For this reason, an online version was also made which was optimised for mobile devices. I will not delve too much in to the workings of the App as it is free to discover on any Apple phone or tablet (http://apple.co/1Dtu227) and on all other phones and tablets at (http://bit.ly/1a08fEm).

The App has proved very popular with my students and I see a bright future for mobile Apps in dental technology. Dental technologists have a wealth of skills and knowledge and I foresee sharing of this via the use of video in the very near future and hopefully in the development of distance-learnt courses that dental technicians can plug into at their place of choice, at a time that suits and as often as they need. I hope that we will be at the forefront of this at MMU.

References

Dredge, S. (2011) Steve Jobs resisted third-party apps on iPhone, biography reveals. The Guardian Online. [Online] [Accessed http://www.theguardian.com/technology/appsblog/2011/oct/24/steve-jobs-apps-iphone

Jones, C. (2013) Apple’s App Store Could Generate $22 Billion in 2016 Revenue. Forbes. [Online] [Accessed on 11th November] http://www.forbes.com/sites/chuckjones/2013/01/10/apples-app-store-could-generate-22-billion-in-2016-revenue/

Lessin, J. E. and Ante, S. E. (2013) Apps Rocket Toward $25 Billion in Sales. Wall Street Journal. [Online] [Accessed http://www.wsj.com/articles/SB10001424127887323293704578334401534217878

Syed, M. (2011) Bounce: Mozart, Federer, Picasso, Beckham, and the Science of Success. Fourth Estate.

Article written by Peter Gough, Senior Lecturer in the school of Healthcare Science.