INTRODUCTION:

Today, computers are an integral part of human’s life and even to some individuals daily activities are difficult or impossible without this device [1,2]. The use of computer technology is growing rapidly and its role in communication services such as internet or email is obvious. For example, all students for academic affairs, research and educational activities, have access to their computers [3,4]. The remarkable thing is the important role of computers in teaching and evaluating the student’s theoretical and clinical knowledge. The use of computers in teaching theoretical courses and preparation of slides for oral presentations are among the routine procedures, but the use of computers in teaching and assessment of clinical subjects is not concerned yet [5-8].

For this purpose, the process of using computers for assessing clinical skills of students is designed in the department of periodontics at Mashhad University of medical science.

Computer based objective clinical examination (COCE):

The COCE consists of two main parts. As the exam performs for a number of students, the exam is presented by the PowerPoint computer software 2013 (Microsoft Corporation, Los Angeles, USA) in an appropriate exam hall was equipped by a data projector for displaying the computer’s output on a white screen or the wall. Both the patient’s information and the exam’s questions are provided by PowerPoint’s slides in the sequence of order. The patient selection and the questions for the exam are designed by the faculty members of the exam committee in the department periodontics at Mashhad University of medical science, Mashhad, Iran. This process may take several sessions and the questions should be approved for the reliability, validity and accordance by the lesson plans of the semester’s curriculum [9-15]. The COCE consists of two parts as follows:

Part 1:

In the first part the students are informed about the patient’s general information and clinical examination in the order of sequence including:

Slide 1 General information:

This slide includes patient’s general information such as age, gender, chief complaint and socioeconomic status.

Slide 2 Medical history:

This slide includes patients past medical history with conferring systemic disorders that may comprise Cardiovascular Diseases, Endocrine Disorders, Hemorrhagic Disorders, Renal Diseases, Liver Diseases, Pulmonary Diseases, Medications and Cancer Therapies, Prosthetic Joint Replacement, Pregnancy or Infectious Diseases. The students should keep in mind any consideration or the inferences of the mentioned systemic disorders on the treatment strategies. This slide may also provide additional information about the laboratory findings that should be considered before treatment planning.

Slide 3 Intra-oral photograph:

This slide presents patients’ intra-oral photograph showing periodontal status. The student must carefully pay attention to the color, shape, form and consistency of the gingiva. Healthy gingiva has a scalloped appearance that fills and fits each interdental space, unlike the swollen gingival papilla seen in gingivitis or the empty interdental embrasure seen in periodontal disease [16]. Healthy gingiva has a "knife-edge" margin, but at the presence of gingivitis or periodontitis the margin’s form changes to what is called "rolled" or "puffy". Healthy gingiva has a firm texture that is resistant to pressure, and the surface texture is often stippled. Unhealthy gingiva, like which is happens during gingivitis and periodontitis, is often swollen and less firm. Healthy gingiva has an orange-peel like texture that is described as surface stippling. Healthy gingiva’s color is described as "coral pink." Red color of the gingiva can signify inflammation, like gingivitis or periodontitis that should be distinguished at the end of part one by the students [17,18].

Slide 4 Periodontal chart:

This slide represents the periodontal chart of the patient. A perio-chart is a graphical tool for organizing all the important information about the patient’s periodontal status. The perio-chart is typically made by a periodontist or a hygienist, who checks out the gingiva with periodontal instruments and draw the chart with hands or digitally by computer software. The information that may be described in the perio-chart includes tooth decays, cavities, missing teeth, the depths of periodontal pockets, the presence of crowns, bridges and removable prosthetic teeth, tooth mobility, bleeding on probing, furcation involvements, gingival recessions and the level of mucogingival junction. The perio-chart can be graphical or pictorial and represents the attachment loss which may be the result of periodontitis [17-21].

Slide 5 X-Ray views:

This slide displays the X-Ray (OPG or Orthopantomogram) radiographic appearance of the patient. An OPG is a panoramic x-ray of the lower face, which displays all the teeth of both upper and lower jaws on a single screen. It demonstrates the number, position and growth of all the teeth, including those that have not yet erupted or impacted. An OPG may reveal maxillary sinus and temporo-mandibular joint (TMJ) problems. It also displays the horizontal and vertical alveolar bone loss in the sequence of periodontitis, which is necessary for assessing the overall and individual tooth prognosis and treatment planning [17-21].

Fig.1. The power point presentation of part 1 exam. Each slide presents as a single screen for at least 3 minutes.

Part 2

In this part the students must answer the questions that are provided by each slide.

Slide 6 Diagnosis:

The student should first determine whether disease is present; then identify the disease’s type, extent, distribution, and severity for achieving the total score. In general, they fall into the following two broad categories:

1 The gingival diseases and their classification. Plaque induced versus non-plaque induced for the etiology, localized versus generalized considering the extent and marginal, papillary or diffuse due to the areas of gingivitis that are involved should be identified by the students.

2 The various types of periodontitis including Chronic, Aggressive, necrotizing ulcerative or the periodontal manifestations of systemic diseases if present should be recognized by the students. The periodontal diagnosis is determined after the careful analysis of the patient history and the evaluation of the clinical appearance as well as the results of various tests (e.g., probing, mobility assessment, radiographs and blood tests). Diagnostic procedures must be systematic and organized like localized/generalized, mild/moderate/severe, chronic/aggressive/ necrotizing ulcerative/systemic manifested periodontitis.

Slide 7 Radiographic interpretation:

Radiographs are important for diagnosis of periodontal disease, estimation of severity, determination of prognosis, and evaluation of treatment outcome. In this slide the students must identify bone destruction, changes in the lamina dura, endodontic periapical and periradicular lesions, patterns of bone loss, such as vertical or horizontal and furcation involvements in the process of periodontitis progression.

Slide 8 General or Overall Prognosis:

The prognosis is a prediction of the treatment outcome of the disease based on a general knowledge of the severity and risk factors for the disease. The students must determine the prognosis after the diagnosis is made and before the treatment plan is established.

Types of Prognosis include:

A. Good prognosis means that etiologic factors are controlled and adequate periodontal support is present for tooth maintenance.

B. Fair prognosis means the attachment loss is about 25% and/or Class I furcation involvement, but with good patient compliance.

C. Poor prognosis means the attachment loss is about 50%, Class II furcation involvement (location and depth of the furcation area, make maintenance possible but difficult) and tooth mobility of grade 1 (0.2-1mm horizontal movement) may be present.

D. Questionable prognosis means the attachment loss is more than 50%, poor crown-to root ratio, Class II or Class III furcation involvements and tooth mobility of grade 1 (0.2-1mm horizontal movement) may be present.

E. Hopeless prognosis: Inadequate attachment or support to maintain tooth, so it would be better to extract the tooth.

The prognosis can be divided into overall prognosis and individual tooth prognosis. The overall prognosis is related to the dentition as a whole. Factors that may influence the overall prognosis include patient age, current severity of disease, systemic factors, habits such as smoking, the presence of plaque, calculus, and other local factors and importantly patient compliance and plaque control [17-21].

Slide 9 Individual prognosis:

The individual tooth prognosis is determined after the overall prognosis and is affected by it. The factors that should be considered by the students while determining the individual prognosis include subgingival restorations, short or tapered roots, cervical enamel projections, enamel pearls, bifurcation ridges, root concavities, developmental grooves, root proximity, furcation involvement, tooth mobility and root resorption or decays.

Slide10 Treatment planning:

After the diagnosis and prognosis have been established, the students must design and write the treatment plan that includes the following stages:

Preliminary Phase:

In preliminary Phase students must focus on the treatment of dental, periapical or Periodontal emergencies and extraction of hopeless teeth.

Phase I Therapy (Nonsurgical Phase):

In this phase of the treatment plan students must focus on plaque control and patient oral hygiene education, diet control, scaling and root planning, correction of restorative and prosthetic causative factors, removing of caries and restoration, antimicrobial therapy (local or systemic), occlusal adjustments, minor orthodontic movements and a provisional prosthesis.

Phase II Therapy (Surgical Phase):

In this phase of the treatment plan students must focus on periodontal therapies including different surgical flap procedures and surgical placement of dental implants.

Phase III Therapy (Restorative Phase):

In this phase of the treatment plan students must focus on placing final restorations, fixed and removable prosthodontic appliances.

Phase IV Therapy (Maintenance Phase):

In this phase of the treatment plan students must focus on periodic evaluation of oral hygiene, plaque and calculus, occlusion, tooth mobility and other pathologic changes [12-25].

Fig. 2. The power pint presentation of part 2 COCE exam. Each slide is presented as a single screen for at least 5 minutes.

RESULTS AND CONCLUSION:

COCE is made up of at least 10 slides about a periodontal patient that has designed by expert examiners and consists of 2 main parts. In part one; students are informed about the patient’s general information, clinical examination and radiographic findings of the patient. In part 2 students must answer the questions about diagnosis, prognosis and treatment planning. COCEs take place nationally at the university despite decentralized traditional exams that would not be fair. Despite old subjective marking system, COCEs are reliable and unique objective exams for assessing student’s clinical skills and could be the gold standard of clinical assessment in the field of dentistry and periodontology [25-29]. The experience of the author is that COCEs are at least 50% more effective than traditional exams for assessing and improving the periodontal knowledge of the students of dentistry.

ACKNOWLEDGMENTS:

I take this opportunity to appreciate all of the Mashhad Department of Periodontology and Implant dentistry faculty members for their help and support. The alphabetical list of professors includes Hamid Reza Arab, Seyed Ali Banihashemrad, Kazem Fatemi, Habib Allah Ghanbari, Amir Moien Taghavi, Nahid Nasrabadi, Mehrdad Radvar, Mohammad Ebrahim Rahmani, Naser Sargolzaei, Farid Shiezadeh, and Mahmoud Tamizi. I thank all of them for the constant encouragement, support and attention.

Declarations of interests:

The author confirms that this article content has no conflict of interest.

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Received on 11.11.2018 Modified on 14.12.2018

Research J. Pharm. and Tech. 2019; 12(4):1615-1618.

DOI: 10.5958/0974-360X.2019.00269.5