THE USE OF MOBILE-AIDED LEARNING IN EDUCATION OF LOCAL ANESTHESIA FOR THE INFERIOR ALVEOLAR NERVE BLOCK PRIMENA MOBILNOG UČENJA U EDUKACIJI MANDIBULARNE ANESTEZIJE

Backgroud/Aim. Dental education has developed over the years, and various technologies have been included in the curriculum. Considering the fact that mobile devices are an imperative of modern time, the aim of our research was to evaluate effectiveness of Mobile-Aided Learning on practical administering an inferior alveolar nerve block (IANB). Methods. This prospective study involved 34 students who were randomly divided into two groups: G1 group with 16 students and G2 group with 18 students. Students of both groups previously successfully completed theoretical and practical training provided by the curriculum. For the purpose of additional education, students of the G2 group used a mobile application for 3D simulation of local anesthesia (Mobile-Aided Leaning) outside the dental office for a period of one semester. After that, all students completed a postclinical questionnaire. Results. The average time for performing anesthesia by participants in the G1 group was 70.54 ± 20.16 seconds, while in the G2 group it was 57.13 ± 17.45 seconds, which was significantly shorter. A successful anesthesia application was higher in the G2 group (83.3%) compared to the G1 group (75%). The results of the post-clinical test questionnaire also indicated difference in the mean values of the responses to all questions, which was in favor of the G2 group participants. Conclusion. Application of Mobile-Aided Learning showed a significantly higher efficiency in student education for practical implementation of the IANB.


Introduction
The basic principle of modern dentistry today is painless dentistry.Application of local anesthesia allows the patient maximum comfort and completely painless treatment.Therefore, mastering anesthesia techniques is an important aspect of the dental curriculum 1 .However, learning anesthesia techniques is still a complex process, and moving to work with patients is often very difficult for students 2 .Dental education has developed over the years, and various technologies have been included in the curriculum.In this sense, simulation models of dental education have been used for more than 100 years 3 .They have a significant impact on education in many areas of dentistry such as endodontics, oral hygiene and operative dentistry 3. 4, 5 .This education system contributes to improving psychophysical skills of students before their first clinical experience, their manipulative abilities, increasing patient safety during clinical trials conducted by inexperienced clinicians 3,6 .Today, we became owners of personal computers, the Internet happened, and information and communication technologies (IT) experienced flourishing and irreversibly changed the whole world.Undoubtedly, they unwittingly permeate the sphere of dental education in form of simulation models, complementing conventional teaching in that way.Computer teaching in the health profession, also known as Computer-Aided Learning (CAL), has become a popular means of providing information to students, patients and practitioners 7 .Today, in the context of the widespread use and appearance of mobile devices, such as smartphones and tablets, people can communicate, work, entertain, access the Internet, and even explore and learn.Bearing in mind the fact that mobile devices are an imperative of modern times, the aim of our research was to evaluate the effectiveness of Mobile-Aided Learning on practical application of anesthesia by students who are dealing with implementation of IANB procedure.

Participants
The presented research was approved by the Institutional Review Commission.This prospective study involved 34 students of the fourth year of study at the Faculty of Medicine, the Department of Dentistry, who did not have any practical skill regarding application of the IANB on patients.The participants were randomly divided into two groups: G1 group (control group) with 16 students and G2 group (study group) with 18 students (Figure 1).The students of both groups then successfully completed the theoretical and practical part of education envisaged by the curriculum, and we applied a direct anesthetic technique for IANB 8 .

Mobile-Aided Learning
For the purpose of additional education, students of the G2 Group used the Dental Simulator mobile application (Campinas, SP 13083765, Brazil), which is available for iOS (App Store) and Android (Google Play Store) -Figure 2. After registering, students used an application outside the dental office via "University Mode" in Serbian through Study Mode (where dental students can read technical descriptions, watch clinical and simulation videos and practice) and Simulation Mode (students can simulate dental procedures and get feedbacks, so they can learn their mistakes in 3D) -Figure 3. Through the University Mode, in order to monitor the success of G2 student education, the educator had access to information about each student during exercise (Figure 4).After completing their education and written consent, in the second phase of the research, students applied the IANB to each other (the operator to the receptor) by a direct method.We used 2% lidocaine with adrenaline (40 mg + 0,025 mg) / 2ml (2% Lidokain, Galenika AD, Serbia).The parameter for selecting the side for anesthesia was the presence of at least one tooth of a molar or premolar region with preserved pulp vitality.For this reason, as well as in order to monitor the success of an anesthesia, 15 minutes before and after anesthesia, the vitality of the teeth of these regions was checked by the standard procedure (Roeko Endo-Frost, Coltene Whaledent).The success of education was evaluated through the success of anesthesia, as well as the time of application that included the period from the moment of removal of needle protection until syringe aspirated for negative pressure and observed for the absence of blood.After that, the injection was continued is administred at rate of 0,4 ml over 30 seconds 9 .

Post-Clinical Questionnaire
Additionally, the success of education was measured on the basis of post-clinical questionnaires.After application of anesthesia, participants completed a questionnaire that evaluated their knowledge and skills.Questions were quantified with a 5-point Likert scale, and possible answers and values were: I totally disagree = 1; I partially disagree = 2; abstained = 3; partially agree = 4; I totally agree = 5.

Statistical analysis
Statistical data analysis was performed using IBM SPSS Statistics 22 (IBM Corporation, Armonk, NY, USA).Results were presented as frequency (percent), median (range) and mean±sd.Fisher exact test was used to test differences between nominal data (frequencies).For numeric data with normal distribution independent samples t-test was used to test differences between groups.For numeric data with non-normal distribution and ordinal data Mann-Whitney U was used.All p-values less than 0.05 were considered significant

Results
The examined parameters indicate a significant success of the participants in the G2 group compared to the G1 group.The average time for performing anesthesia by participants of the G1 group was significantly shorter comparing to subjects who were using 3D simulation (Table 1).Also, after additional aided education, participants performed the IANB more successfully, although it was not statistically significant (Table 1).The results of the post-clinical test questionnaire also indicated differences in the mean values of the responses to all questions in favor of the G2 group (Table 2), which was especialy notable (and statistically significant) for answers to the question "I easily identify the exact location of the sting".

Discussion
Many dentistry students point to inadequate preparation for practical use of local anesthesia in clinical conditions 10 , while studies show that even dentists identify the administration of local anesthetics as one of the most stressful procedures in everyday clinical work 11 .It especially applies for the IANB, which is often complex for dentistry students to be understood and performed, primarily due to difficult and insufficiently clear identification of the location of the sting.Researches show that an average person spend up to 5.5 hours with a mobile phone during the day.From that at least 2 hours with the so-called unnecessary content, such as social networking, games etc (source: Flurry Analytics, comScore, Facebook, NetMarketShare.Note: US, Dec 2016).Also, several studies have found that mobile devices today play an important role in education and see the impact and benefits of this device in relation to the point of pedagogical perspective 12,13 .Therefore, our aim was to apply a 3D simulation of the IANB in education of students, beside conventional methods.Also, the learning process which includes simulation techniques allows students to critically evaluate how they felt during the exercise, to practice the same procedure repeatedly without the need for supervision and with synchronous computer feedback 14 , and may have an impact on the level of reliability when applying the first anesthetic procedure 15 .Our study suggests that the model of student education which, in addition to conventional methods, includes mobile 3D simulation, gives better results than the conventional method alone considering skill of providing the IANB.An important parameter that indicates knowledge of the IANB technique and the level of safety in its performance is time required for anesthesia.The procedure for giving anesthesia will be shorter in people with higher level of knowledge and education.In other research, higher education corresponds with shorter time of giving 16 .In our study, the time of anesthesia was statistically significantly shorter in the study group compared to the control, which indicates that training with additional simulations can improve skill of students for the performance of the IANB.Similar results published Lopez et al 17 , pointing the fact that students who were practicing on dental anaesthesia simulation model besides the conventional methods exhibited shorter time of the procedure for the anterior superior alveolar nerve.Perception of students about the level of their knowledge and safety when performing the IANB was measured by a post-clinical questionnaire using the Likert scale.A similar instrument of research was used in other studies 15,18 .Students of the study group had more positive answers to all questions of the post-clinical questionnaire, which was statistically significant for the question "I easily identify the exact location of the sting".The effectiveness of anesthesia was also one of the tested parameters.In our study, the G1 group had a failure rate of 25%, while in the G2 group it was 16.7%.Although the difference was not statistically significant, it could indicate a better knowledge of the technique and self-confidence in performing the IANB.Numerous studies have dealt with the effect of simulation models on education of students in the field of local anesthesia.Marei and Al-Jandan 15 compared theoretical and practical knowledge of students with conventional methods of learning in relation to knowledge when conventional methods were used together with a simulation model (electric phantom).Their results point to a better level of knowledge of students in which the simulation model was used, but the statistical significance existed only in terms of theoretical knowledge.Lopez et al 17 , who used the phantom as a simulation model, also highlighted significantly higher level of self-confidence among students who used simulation models in addition to classical methods.Our study confirms benefits of the use of simulation models as supplemental methods of education of students in providing the IANB.However, we would like to point out that, within the various types of simulation models, the aided learning model used in our study shows numerous benefits.First of all, the advantages of mobile learning are that they are always at hand (having in mind the fact that daily use of the mobile phone is growing day by day) and, financially, they are more profitable because they do not need additional phantoms and tools for exercising.For the development of effective skills, awareness of reasons when and how the error occurred is more important than the final result 19 , and the "University Mode" of the mobile application provides all the information and shows the most common student errors at any time during exercise.

Conclusion
The use of mobile-aided learning exhibited several benefits for student education concerning practical IANB application.Students who used a conventional method and a virtual simulation model exhibited shorter time of anesthesia, showed more self-confidence and had a higher percentage of successful anesthesia.This type of simulation model can be recommended for regular student education.Online First October, 2018.

Table 2 .
Post-clinical questionnaire and values classified according to the Likert scale