All posts by Dr. Glenn Clark

Dr. Glenn Clark

About Dr. Glenn Clark

Dr. Glenn Clark, DDS is an expert on sleep apnea, orofacial pain and oral medicine, and Temporomandibular Joint Disorder (TMJ). Dr. Clark serves as the Director for the Advanced Program in Orofacial Pain and Oral Medicine at the Herman Ostrow School of Dentistry of USC.

Man at the dentist receiving a checkup for his palatal myoclonus

Proposed Mechanism and Treatment of Palatal Myoclonus

Man at the dentist receiving a checkup for his palatal myoclonus

Myoclonus is a frequently observed hyperkinetic movement disorder, which is often classified according to its anatomical origin. [1] Palatal myoclonus is characterized by involuntary palatal contractions, causing clicking tinnitus due to the action of soft palate muscles on the membranous Eustachian tube. [2]

 

Proposed Mechanism

The palatal myoclonus might be secondary to a CNS lesion, however, most of the time will be a disorder of unknown etiology involving involuntary movement of the uvula and soft palate, with movement of the tensor veli palatine. [3]

 

Treatment

In case of an essential palatal myoclonus, without evidence of CNS involvement, the management includes relaxation techniques, voluntary mechanisms (such as Valsalva maneuver), and dental devices.  Medications such as anticonvulsants, benzodiazepines, anticholinergic agents and BoNT-A have been reported with mixed results. [4]

(1) There are maneuvers or sensory tricks that seems to reduce the movements of the palate by altering the position and tone of the muscle involved in altering the pressure in the ear canal.  Some examples are pushing the palate with the thumb, wide mouth opening and Valsalva maneuver. [5] The use of dental devices, such as an acrylic plates, might be useful to improve phonetics and oral motor function. [6]

(2) The use of benzodiazepines (like clonazepam) produces a gamma amino butyric acid (GABA) agonistic property which might be responsible for the reduction of dysfunctional movements.  Other medications that have been used are sodium valproate [7] and piracetam. [8]

(3) The use of BoNT-A to reduce the contractions of tensor veli palatine muscle opens the Eustachian tube and reduces the movement of the palate. [9] [10]

 

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References

[1] Zutt, R., Elting, J., Van Zijl, J., Van der Hoeven, J., Roosendaal, C., Gelauff, J., Tijssen, M. (2018). Electrophysiologic testing aids diagnosis and subtyping of myoclonus. Neurology., Neurology , 2018;90:1-11.

[2] Persaud, R., Garas, G., Silva, S., Stamatoglou, C., Chatrath, P., & Patel, K. (2013). An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Reports, 4(2), 10.

[3] Kitamura, T., Sato, T., Hayashi, N., Fukushima, Y., & Yoda, T. (2015). Essential Palatal Tremor Managed by Cognitive Behavioral Therapy. Case Reports in Dentistry., 2015, 414620.

[4] Pandurangi, A., Nayak, R., Bhogale, G., Patil, N., Chate, S., & Chattopadhaya, S. (2012). Clonazepam in the treatment of essential palatal tremors. Indian Journal of Pharmacology.,44(4), 528-530.

[5] Zadikoff, C., Lang, A., & Klein. (2006). The ‘essentials’ of essential palatal tremor: A reappraisal of the nosology. Brain : A Journal of Neurology., 129(Pt 4), 832-840.

[6] Carlstedt, K., Henningsson, G., & Dahllöf, G. (2003). A four-year longitudinal study of palatal plate therapy in children with Down syndrome: Effects on oral motor function, articulation and communication preferences. Acta Odontologica Scandinavica, 61(1), 39-46.

[7] Borggreve, F., & Hageman, G. (1991). A case of idiopathic palatal myoclonus: Treatment with sodium valproate. European Neurology, 31(6), 403-404.

[8] Campistol-Plana, J., Majumdar, A., & Fernández-Alvarez, E. (2006). Palatal tremor in childhood: Clinical and therapeutic considerations. Developmental Medicine and Child Neurology.,48(12), 982-984.

[9] Cho, J., Chu, K., & Jeon, B. (2001). Case of essential palatal tremor: Atypical features and remarkable benefit from botulinum toxin injection. Movement Disorders : Official Journal of the Movement Disorder Society., 16(4), 779-782.

[10] Carman, K., Ozkan, S., Yarar, C., & Yakut, A. (2013). Essential palatal tremor treated with botulinum toxin. Pediatric Neurology., 48(5), 415-417

Man with Oral Motor Tic - Facial Grimacing - Orofacial Pain and Oral Medicine Postgraduate Dentistry Training Course - USC Dentistry Online

Mechanism and Treatment of Orofacial Motor Tics

Man with Oral Motor Tic - Facial Grimacing - Orofacial Pain and Oral Medicine Postgraduate Dentistry Training Course - USC Dentistry Online

Rather than a voluntary movement, a tic is a movement which relieves a voluntary urge, and this is the key characteristic which differentiates a tic from another movement disorder.

Motor tics of the orofacial area include tongue protrusion, facial grimacing, blinking, and facial twitching and cheek sucking. Orofacial motor tics usually involve the peri-oral muscles (e.g. buccinator, orbicularis oris, tongue, and levator anguli oris).

 

Proposed Mechanism

The cortico-basal ganglia pathway is involved in normal motor control and implicated in multiple movement disorders, so a dysfuntion of this area will produce brief, repetitive muscle contractions. [1]

The most common and severe form of a multiple tic disorder is Tourette’s syndrome, which includes motor and vocal tics.  This condition has been related with abnormalities within cerebro-basal ganglia circuits. [2]

Like what you’re learning? Test your diagnosis skills with USC’s Virtual Patient Simulation. Review real-life patient histories, conduct medical interviews and exams, make a diagnosis, and create a treatment plan for patients experiencing orofacial pain.

 

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Treatment

Oral tics might impact patient functionality, since they could interfere with communication and social interaction.

 

1. Behavioral Therapy

If there is no actual change in the cerebro-basal circuits, some tics might be subject to voluntary inhibitory control. [3]  Motor inhibition and attentional processing are tightly linked and both processes might rely on similar cognitive and neural mechanisms, providing the basis for tics inhibition with behavioral therapy. [4]

There has been some development in the application of technology for tic’s management, with interactive online treatments based on comprehensive behavioral interventions. [5]  Some limitations for this type of approach are age of patients, tic severity, profile of comorbidities, treatment availability, cost, and insurance coverage. [6]

 

2. BoNT-A Injections

As with hyperactive tongue problems, there is a need to explore better when, where and to what degree BoNT-A may become useful in management of facial muscle, buccinator, orbicularis oris and tongue-based motor tics.

One paper reviewed the results of 450 patients who had various types of motor tics associated with Tourette’s syndrome who were treated with BoNT-A. [7]  They used the Yale Global Tic Severity Scale and determined that BoNT-A in combination with baclofen was very effective, safe, and reliable in the treatment of tics associated with Tourette’s syndrome.

Another paper also described the effect of BoNT-A on 35 patients with long standing motor tics associated with the Tourette’s syndrome. [8]  They reported that the patients rated their improvement with this treatment as a mean of 2.8 on a scale from 0 to 4.

A recent systematic review indicated that there is uncertainity about botulinum toxin effects in the treatment of focal motor and phonic tics, and the quality of the available evidence was categorized as very low. [9]

Related Reading: Chemodenervation Injections for Treating Oromandibular Dystonia

 

3. Controlling Alterations of Methylation Levels of Dopaminergic Genes

The blockade of the striatal dopamine-D2 receptors with dopamine receptor antagonists produces a tic-reducing effect. [10]

It has been proposed that if the alterations of methylation levels of dopaminergic genes are controlled, there will be a reduction of spontaneous fluctuations of tics. [11]

 

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References

[1] McCairn, K., Bronfeld, M., Belelovsky, K., & Bar-Gad, I. (2009). The neurophysiological correlates of motor tics following focal striatal disinhibition. Brain : A Journal of Neurology., 132(Pt 8), 2125-2138.

[2] McCairn, K., Iriki, A., & Isoda, M. (2013). Global dysrhythmia of cerebro-basal ganglia-cerebellar networks underlies motor tics following striatal disinhibition. The Journal of Neuroscience : The Official Journal of the Society for Neuroscience., 33(2), 697-708.

[3] Ganos, C., Rothwell, J., & Haggard, P. (2018). Voluntary inhibitory motor control over involuntary tic movements. Movement Disorders, Movement disorders , 2018.

[4] Hilt, P., & Cardellicchio, P. (2018). Attentional bias on motor control: Is motor inhibition influenced by attentional reorienting? Psychological Research Psychologische Forschung., Psychological research Psychologische forschung. , 2018.

[5] Conelea, C., & Wellen, B. (2017). Tic Treatment Goes Tech: A Review of TicHelper.com. Cognitive and Behavioral Practice.,24(3), 374-381.

[6] Fründt, O., Woods, D., & Ganos, C. (2017). Behavioral therapy for Tourette syndrome and chronic tic disorders. Neurology.,7(2), 148-156.

[7] Awaad Y. Tics in Tourette syndrome: new treatment options. Journal of Child Neurology, 1999 May, 14(5):316-9.

[8] Kwak CH; Hanna PA; Jankovic J. Botulinum toxin in the treatment of tics. Archives of Neurology, 2000 Aug, 57(8):1190-3.

[9] Pandey, S., Srivanitchapoom, P., Kirubakaran, R., & Berman, B. (2018). Botulinum toxin for motor and phonic tics in Tourette’s syndrome. The Cochrane Database of Systematic Reviews., 1, CD012285.

[10] Mogwitz, S., Buse, J., Wolff, N., & Roessner, V. (2018). Update on the pharmacological treatment of tics with dopamine-modulating agents. ACS Chemical Neuroscience., ACS chemical neuroscience. , 2018.

[11] Müller-Vahl, K., Loeber, G., Kotsiari, A., Müller-Engling, L., & Frieling, H. (2017). Gilles de la Tourette syndrome is associated with hypermethylation of the dopamine D2 receptor gene. Journal of Psychiatric Research., 86, 1-8.

Dentist Taking an Online Distance Education Course in Postgraduate Dentistry from the Comfort of Their Home

Distance Education vs. Correspondence Courses

Dentist Taking an Online Distance Education Course in Postgraduate Dentistry from the Comfort of Their Home

Not all online programs are the same. Let’s look at the definition of a correspondence course versus an eLearning experience.

 

Why is the distinction important?

While there has been no payment made by St. Mary-of-the-Woods College, the U.S. Department of Education’s Office of the Inspector General categorized courses given at this college as “correspondence courses” not as distance education courses.

This is critical as students qualify for financial aid dollars when they take distance education courses, not correspondence courses. The Inspector General suggested that St-Mary-of-the-Woods college should refund $42 million in federal financial aid dollars that it disbursed to students over a five-year period.

At any time in the future a college can be inspected and if instructors are found to be offering correspondence course, this finding can be very financially damaging to the University.

 

Correspondence Courses vs. Distance Education

To understand the difference, let’s look at the Higher Education Act of 1965 and it’s subsequent amendments. In part 600, Institutional Eligibility, the HEA-1965 defines a “Correspondence” course as one that has the following elements:

  • Course materials given by mail or digitally.
  • Exams are all non-proctored (open book).
  • Limited, irregular faculty-to-student (F2S) interactions.
  • Almost all interaction initiated by student.
  • Courses are typically self-paced.
  • Emails to instructor gets no response.
  • Help requests responses only staff, not faculty.
  • There are no office hours.
  • Student must trouble shoot own problems.
  • Course have no chatroom for students.
  • If discussion forum exists, no faculty input.
  • All course work is automatically graded.

Like what you’re learning? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

 

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Other Styles of Education

Here are five other popular styles of education:

 

1. Tutorials at Oxford and Supervisions at Cambridge

The two oldest and quite highly ranked universities in the world are Oxford and Cambridge. At these institutions they have used small group interactions between faculty and students which they call either tutorial or supervision sessions.

Oxford’s student tutorials may be more academically challenging and rigorous than a standard lecture. At each session students must orally communicate, defend, analyze, and critique the ideas of others as well as their own.

 

2. Large Lecture Hall Lectures

Some colleges and universities use large lecture halls to provide content to a very large group of students (usually taken 1st-year core courses). As we mentioned in the first lecture in this course, these lectures are usually not effective as there is not interactivity and even if you wanted to ask your students questions, the group is too big.

Related Reading: How to Use Guided Discovery Questions to Deepen Learning

 

3. Project-Based Learning Group Sessions

A style of education similar to Oxford or Cambridge tutorials is Project-Based Learning (PBL). In a PBL class the instructor gives the students a problem, the students identify their learning needs, they are assigned, and students go off and research these LNs. At the next session the students review what they have learned and then the instructor gives them another piece of the problem to work on. Like the Oxford and Cambridge tutorials, PBL is moderately expensive as the faculty to student ratio is usually 1:8.

 

4. Asynchronous Lectures Using Video Recording

Non-interactive recorded lectures are not better than a traditional lecture hall (F2F) lecture, just more convenient to watch!

 

5. Flipped Classroom Style Teaching

Flipped classrooms are great if the students watch the lectures before hand! The problem again is the faculty student ratio as most of the time the number of students that can work or discuss a problem is small (8-10 students in a discussion group)

 

Distance Education

Let’s review distance education and more specifically hybrid online learning! A hybrid style of distance education includes F2F instruction, online collaboration, and self-paced learning.

In part 600, Institutional Eligibility, the HEA-1965 lists the following elements that are used in distance education:

  1. Regular and substantive F2S interactions
  2. Interaction is synchronous or asynchronous
  3. Regular instructor initiated communication
  4. Instructor feedback on student progress
  5. Regular F2S interaction using discussion boards, video conference, or email/text.
  6. Faculty monitored student-run chatroom, option and guided & structured tasks with regular input from faculty.

Beyond audits by the Department of Education Office’s Inspector General, the distinction between distance education courses and correspondence courses is important because it is a rapidly growing style of education and if done right it is extremely valuable and if done wrong it is a rip-off! See the figure below showing the ever increasing number of online students.

 

 

Online vs. Traditional Education

Below are three studies that researched and discussed this issue along with my comments.

1. OB Palpation Skills for Web vs. Traditional Instruction

Mangala Gowri P, et al. compared web-based and traditional instructional methods to teach obstetrical palpation for antenatal mothers among B.Sc(N) II year students. The study randomly selected two groups of 15, 2nd-year nursing students in each group. Group 1 had web-based instruction while group 2 had traditional instruction in class. The study compared obstetrical palpation skills and knowledge, and the outcome was a test of both knowledge and OSCE skills.

Results

The study found that knowledge on obstetrical palpation was higher in the web-based group, and OSCE scores on OB palpation were higher in the traditional training group.

Overall, the statistical analysis showed no significant group differences. In conclusion, both methods worked but the combination of these two methods of education may further enhance the students skill acquisition level.

Comments

The convenience of recorded lectures is very important to students but a recording without interaction is not better than a F2F lecture.

 

2. Grade-Based Student Learning Outcomes

Cavanaugh JK and Jacquemin SJ compared a large sample of grade-based student learning outcomes in online vs. face-to-face courses. The study used grade data from 5,000 courses taught by more than 100 faculty over 10 terms at a public, four-year university. They used multiple regression analysis and controlled demographic and GPA confounders.

Results

  1. A significant difference was seen between the course formats.
  2. Difference was probably negligible however (<0.07 GPA pts).
  3. Primary influence on course grades was student GPA.

In conclusion, students with higher GPAs will perform even better in online courses. Conversely, struggling students perform worse when taking courses in an online format vs F2F.

Comments

When you are taking classes alone at home, you must be very disciplined otherwise you will not find the time to watch the lectures. I assume higher GPA students are more disciplined and therefore do better than low GPA students in the online world.

 

3. Blended vs. Traditional Course Delivery

Tseng H and Walsh EJ Jr. studied the impact of blended versus traditional course delivery on students’ motivation, learning outcomes, and preferences. The study compared results from two groups of 26 students taking an English Literacy course across three outcomes: 1.) level of learning motivation, 2.) level of learning outcomes and skills, and 3.) learning achievement. Group 1 used a traditional format and group 2 used a blended format.

Results

  1. Group 2 (blended) had a significantly higher learning motivation
  2. Group 2 (blended) had a significantly higher learning outcomes.
  3. Final grades showed no significant group difference.

Blended learning students indicated that they would take more blended classes and would recommend them to their friends.

Comments

When you say blended this means an online element and a F2F component, which in my opinion is the best approach.

 

Can Hybrid Online Teaching be better than F2F?

Yes and no. Yes, if you compare a great hybrid online program to a traditional one-way lecture. No, but equivalent if you compare a great hybrid online program to active learning face-2-face classes. If you compare “correspondence type” online education to active learning F2F, I’d say it’s not even close. Outcomes are more important than student preference, but hybrid online is preferred, however an undisciplined student will do poorly in both formats.

 

What is good online teaching?

Here are some elements:

  • Recorded interactive and focused lectures with interactive elements such as pop-up questions and hotspots
  • Course manuals with interactive elements (e.g.polls, Easter eggs, thought-provoking discussion questions)
  • Hybrid courses where students are rewarded with accomplishment badges
  • Small group video conferences where live F2S discussion occurs and student presentations are given
  • Practicums where experience is gained and reflective journals are kept and commented on

 

Explore USC’s Postgraduate Dentistry  Programs

Like what you’re learning? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

 

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Woman on a Fixed-Time Session Conference Call - Online Postgraduate Degree Program in Orofacial Pain

Create an Asynchronous eLearning Experience in 4 Easy Steps

Woman on a Fixed-Time Session Conference Call - Online Postgraduate Degree Program in Orofacial Pain

Before we cover the four steps for creating an asynchronous eLearning experience, here are three studies that demonstrate the benefits of using interactive video content in eLearning courses.

 

The Effectiveness of Embedded Content as form of Active Learning

The best evidence for active learning was the systematic review and meta-analysis we have already discussed by Freeman et al.! Below are some additional abstracts which also researched this topic.

In the spring of 2013, Vural, OF published a study on the impact of a question-embedded video-based learning tool on eLearning in the journal of Educational Sciences: Theory & Practice journal. They held two interventions: one with question-embedded video, and one without questions. The video covered the same content and all used the same instruments to assess student achievement. Before and after the computer literacy course, 318 teacher education students were surveyed on their computer knowledge.

Results: Recording a Video Without Interactive Elements is not Enough!

  1. Q-embedded video promoted better student learning.
  2. Q-embedded video improved student-student interactions.
  3. Q-embedded video increased time with learning materials.

Incorporating video into eLearning environment does not always result with improving learning. However, using Q-embedded interactive videos leads to better learning outcomes and higher learner achievement

 

Like what you’re learning?

Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

 

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Impact of Interactive Video on Learning Effectiveness

Zhang D, et al. assessed the impact of interactive video on learning effectiveness in relationship to instructional video in eLearning. They examined the effect of interactive video on learning by assessing the test results and student satisfaction of four groups:

  1. Interactive video
  2. Non-interactive video
  3. eLearning but without video
  4. Traditional classroom environment (control condition)

Results

The findings suggest that it is important to integrate interactive instructional elements into video eLearning systems.

  1. Students given interactive videos had higher tests scores.
  2. Student given interactive videos had higher learner satisfaction.
  3. Students given non-interactive video did not improve vs control.

 

Course Satisfaction and Usefulness

Shu-Sheng Liaw and Hsiu-Mei Huang in their study, Perceived satisfaction, perceived usefulness and interactive learning environments as predictors to self-regulation in e-learning environments, published in volume 60 of the Computers & Education journal found that all three variables (perceived satisfaction with the online course, perceived usefulness of the course, and the course’s interactive learning environment) predicted high degree of self-regulation among a group of 196 university students. The authors noted that both “perceived usefulness” and “perceived satisfaction” were strongly influenced by the presence of an interactive learning environment.

This study shows that if the interactive elements are well thought out and the student’s see them as useful then the students spend more time engaged with the course!

There is reasonable evidence to support the effectiveness of “embedded content” in asynchronous eLearning materials (video lectures, course manuals). It certainly is easier to just walk into a class of students and talk to them, but with distance education this is not possible! Yes, it is more work initially, but if a lecture is used more than once this “evens out” and interactive videos are more effective!

 

How to Create an Asynchronous eLearning Experience

Asynchronous interactive eLearning experiences involve several elements:

  • You must record your presentation, and embed questions and hotspots inside your presentation
  • Include guided discovery questions, scenarios, or patient cases, for discussion at a fixed-time interaction
  • I strongly suggest a custom course manual that links directly with your focused short up-to-date recorded presentation
  • I also strongly suggest including in the manual a set of embedded questions, polls, and even some Easter Eggs
  • Students can post their answers to an online discussion board and the video conference is an opportunity to review and comment

 

What is a fixed-time interaction?

A fixed-time interaction is a weekly video conference where students and instructors connect.

Students and Faculty Meet for a Fixed-Time Session During an Online Postgraduate Dentistry Degree Program in Orofacial Pain and Oral MedicineStrictly speaking, this is not asynchronous since you and the students are in the same place at the same time, but any hybrid educational program should have these.

I recommend requiring students to keep their cameras on at all times during the conference. If you want to have your students on camera so you can see them, then I recommend not having  more than 10 students in a video conference, which means you may need to host multiple sessions or use breakout rooms.

The limitations of technology come into play however. The students have to have a reasonable bandwidth on their individual internet service and if you’re holding the conference at busy traffic times, you will still have problems with voice and video drop-out, jitter and even freezes. Overall these video conferences usually work well, although some students will have to upgrade their service.

 

1. Create a Customized Slide Deck

A Customized PowerPoint Presentation

If you know where you want to add pop-up quizzes and hotspots, I suggest customizing your PowerPoint deck before recording. Specifically, I suggest you add a place holder slide where you want to input the hotspot and where you want to have a pop-up quiz.  To reduce cognitive overload, I suggest using only 20 slides.

 

2. Record a Lecture

To record a lecture, at a minimum, you need a laptop with a microphone and a camera built-in and a recording-editing software on the computer. The built-in camera and microphone will not be the best sound or video but it will work.

As you get more creative you will need better lighting, a better microphone and a better camera. Once you have mastered this, you can even move onto more studio-like recording where you are standing up and using a light-board to illustrate your most important points.

 

3. Embed Interactive Elements in your Video

Video Editing Software With Markers where Interactive Content Should be Embedded

You will need a video editing software program to capture your video and PowerPoint slides. I like the software Camtasia. It is great and in my opinion an easy-to-use video editing tool. Once you have the recording finished, load it into the editing timeline and you can embed interactive elements.

Hotspots

Inside Camtasia you can stop the video so students can link out to a picture, video or maybe a table with data. I like to use YouTube videos that are 1-2 minutes long to supplement my lectures. The placeholder slide might say, “Click here to watch a YouTube video on Flipped Classrooms!”

YouTube has a massive amount of content. It has a lot of user-generated content where patients share their stories. Some of these videos are cheesy, but some are quite good and present a disease to a student who has never encountered a patient with such a condition. Just make sure you screen the videos so you don’t link out to inappropriate or misleading information.

 

4. Build a Custom Course Manuals

To create an interactive course manual, you need to convert your PowerPoint slides and text into a document. You need to pull the photos from the slides into the document, write your thoughts down, and provide citations, abstracts, and other scholarly supportive material to your lecture points.

The interactive elements that can be built into a course manual are mostly of two types:

  1. Quizzes (I like to use Poll Everywhere)
  2. Easter Eggs (using augmented reality software)

Place active links inside the document that will, when clicked on, take the student out to a multiple choice question students can answer to gain extra credit or experience points.

Related Reading: How to Motivate Students: EPAs, Badges, and Experience Points

 

Easter Eggs

Easter eggs can be interactive 3D models, short animations, videos, audio clips, or even 2D photos that pop up when you view an embedded QR code. These Easter eggs should supplement the content being discussed in the course manual.

On the pop-up that becomes visible, a word or number ID should provide the answer to a question in the course manual. Students who open the QR codes will get the question correct and receive bonus points that they can use to earn a better grade or badge.

 

11 Elements to Incorporate in your Teaching Style

Here is a consolidated list of the elements we covered in this article:

  1. Use focused, short, up-to-date lectures
  2. Don’t cause cognitive overload
  3. Use guided discovery questions
  4. Hold discussion sessions (tutorials) on guided discovery questions
  5. Record your lectures
  6. Embed pop-up questions and extra content links
  7. Create interactive course manuals
  8. Embed polls, Easter eggs and deep thought questions
  9. Require a reflective journal for observational practicums
  10. Require attendance at video conference sessions
  11. Require participation on web-based discussion board

 

Explore USC’s Postgraduate Dentistry  Programs

Like what you’re learning? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

 

Get More Information

 

Older Man Studying for an Online Postgraduate Degree in Orofacial Pain and Oral Medicine on his Laptop at Home

How to Motivate Students: EPAs, Badges, and Experience Points

Older Man Studying for an Online Postgraduate Degree in Orofacial Pain and Oral Medicine on his Laptop at Home

The final installment in the F.I.S.G.R. acronym for effectively teaching online is “R,” which stands for rewards. In general, the principle is that rewards do in fact motivate students.

Before explaining badges and experience points, it is important to explain milestones and EPAs. As the name implies, milestones mark a student’s growth or progress towards the ultimate goal. EPAs are relatively new on the residency training scene.

 

Entrustable Professional Activities

EPA stands for Entrustable Professional Activities. Completing an EPA and being certified as completing it is critical in the education of both medical and dental residents. EPAs are used to determine when a resident (medical or dental) can be indirectly supervised as opposed to directly supervised. This is an important distinction since direct supervision requires the attending faculty be present when a resident works with a patient but indirect supervision does not.

The “father of EPAs” is Dr. Ollie Ten Cate who is a MD in the Netherlands. In his paper, Nuts and Bolts of Entrustable Professional Activities, in the Journal of Graduate Medical Education (March, 2013) he defines what EPAs:

  1. An EPA is a competency-based education target.
  2. Completing an EPA satisfactorily allows a resident to work with “indirect supervision” rather than direct.
  3. A program’s EPAs defines “proficiency to graduate.”
  4. Medical competencies are defined by CanMEDS.

In summary, EPAs use CanMEDS but translate these competencies into behaviors that occur in the actual real world of medical practice.

 

What are CanMEDs and OSCEs?

CanMEDs define needed qualities of a professional. The word is derived from two words: Canadian and Medical. They were originally written and published by Royal College of Surgeon of Canada and define the seven essential qualities and behaviors a physician needs to exhibit including being a: medical expert, collaborator, leader, health advocate, scholar, and professional.

Once you have EPAs (e.g. student must be able to conduct a thorough patient interview), you then need to have a set of Objective Standardized Clinical Examinations (OSCEs) that can be used to assess the students ability on this specific EPA.

 

Types of Supervision for Residents

The American Council of Graduate Medical Education (ACGME) defines three types of supervision they endorse:

  1. Direct Supervision – supervising doctor is physically present with the resident and patient.
  2. Indirect Supervision – supervising doctor is not physically present but immediately available to the resident and patient.
  3. Oversight – supervising doctor is available to review procedures/encounters with feedback provided soon after care is delivered.

 

Review and Reflection

Because none of the three types of ACGME supervision work if you are trying to train a resident in another city, state, or country, there is another type of supervision that is applicable in a hybrid online residency program called “Review and Reflection.”

Of course, if a faculty member has a resident who is in a location where the faculty is not physically present and licensed, they cannot be involved in direct, indirect or oversight supervision of patients as this could be considered practicing without a license.

Review and Reflection is a “non-supervision” style of supervision that involves discussions of patient care using de-identified cases and guided discovery questions. Review and Reflection can not be used not to directly or even indirectly guide ongoing treatment of a patient but instead to teach the principles of evidence-based care. Using “exemplar” de-identified cases the faculty can discuss, comment and teach the principles underlying Diagnosis and Treatment.

In our hybrid online “residency” training programs residents are onsite for part of their training so the supervision is different depending on the residents location. When residents are onsite they participate in direct, indirect and oversight. When they’re online we use we-identified exemplar cases, virtual patient cases, reflective journal reviews, and a final portfolio review.

 

How to Motivate Students and Increase Performance

F.I.S.G.R. Initialism - "R" Stands for RewardsUsing Rewards to Increase Student Performance and Participation

In this section we’ll cover using rewards to increase student performance and engagement through achievement badges, experience points, and we’ll cover the effects of game-based learning.

 

What are achievement badges?

Badges reward students for passing milestones and mastering specific EPAs. The future will tell if badges become more important in the professional world but certainly badges have personal value and maybe some will have a consumer value.

The personal value of badges is that they represent skills, competencies, activities, and achievements. If by earning a badge, an individual gains greater insight into themselves and their abilities, then the value of the badge is extremely high but entirely dependent upon the perception of the earner. The consumer value of badges largely depends on the consumer or market value. Earning a badge, or a series of badges is like earning currency. Some are silver while other badges are gold.

While programs will differ in how they award badges, students at USC will get a badge only after they:

  1. Successfully pass a USC course (usually 1 or 2 units) with a grade of B or higher;
  2. Pass a set of associated objective standardized clinical examinations [OSCEs] relevant to skill the badge represents
  3. Gain a minimum number of experience points (XPs) [documented with a mini-portfolio submission]

 

Experience Points

Experience Points (XPs) are gained based on experiences students have in an observational practicum and that are clearly documented in their “reflective journals.” Students must carefully document their experiences on their observational practicum and respond to all faculty questions in a Reflective Journal to earn XPs.

Related Reading: How to Increase Student Performance with Active Learning

 

What is the evidence that badges motivate students?

A 2016 and 2017 study examined student attitude about badges and found they were motivational and popular.

 

Game-Based Learning

Davidson SJ and Candy L.’s “Teaching EBP Using Game-Based Learning: Improving the Student Experience,” article from Worldviews on Evidence-Based Nursing (August 2016) evaluated game-based learning (GBL) tools.

Using an online nursing course with GBL methods student satisfaction was assessed at the middle and end of the term. The game platform’s analytics and narrative comments were used to assess student learning with end of course grades.

Results

  1. Students showed high satisfaction with the course.
  2. 87% of the students (26/30) continued using game even after getting enough points to get an A grade
  3. Seven students completed every learning quest in game
  4. 17/30 students earned a final course grade of A+
  5. 13/30 students earned an A grade.

They concluded that individualized feedback and use of badges promoted student engagement and mastery.

Rather than use quizzes and a final exam you could use a complication of experience points and badges to issue a grade in a course to motivate students to engage in interactive activities.

 

Letter Grade to XP Conversion Table

Experience Points (XPs)Required BadgesLetter Grade
951 or higher5A+
901 - 9505A
850 - 900-A-
800 - 849-B+
750 - 799-B
700 - 749-B-
686 - 699-C+
675 - 6854C
650 - 674-C-
601 - 649-D+
551 - 600D
550 and belowF

 

One example of how we use game-based learning is through our Virtual Patient Game, which allows dental students opportunities to hone their diagnostic skills based on simulations of real-life patient case studies.

 

Play the Virtual Patient Game

 

Student Perceptions of Digital Badges

Here is a nice article by Fajiculay JR, et al’s, “Student perceptions of digital badges in a drug information and literature evaluation course,” from the Currents in Pharmacy Teaching and Learning (September 2017), which assessed student attitude about badges. Student perceptions were assessed with pre- and post-learning surveys.

Results:

  1. The response rate was 69% (106/153).
  2. At baseline, 53% of respondents thought badges could help.
  3. Badges posted on both LinkedIn (68%) and Facebook (19%).
  4. 73% with earned badges claimed increased confidence.
  5. 55% with earned badges claimed better knowledge

Digital badges were perceived by students as a positive adjunct to learning and may provide a novel mechanism for development of an electronic skills-based portfolio. Digital badges also helped increase confidence in course material, helped recall information for a quiz or exam, and should be implemented into other courses.

 

4 Things to Remember

One thing you must not do is expect that a course without a tangible and immediate benefit to the student will be popular.

That said here are the three things you SHOULD do:

  1. Design a set of competencies (badges) for each course and make sure each one has real value to the student.
  2. Place these achievement badges in a accessible password protected web-enabled locker.
  3. Each badge should contain metadata documenting the credentials of the issuer and all requirements to get it.

 

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Young Man Raising His Hand During an Online Postgraduate Dentistry Degree Video Chat

How to Use Guided Discovery Questions to Deepen Learning

Young Man Raising His Hand During an Online Postgraduate Dentistry Degree Video Chat

Guided discovery means that the instructor creates questions and suggests resources for students to research and on which to report. These questions are typically given to students at the end of a lecture or following a patient case problem.

The article, Student perceptions on using guided reading questions to motivate student reading in the flipped classroom, set out to determine the educational value of Guided Reading Questions (GRQs), and found that the use of GRQs positively impacted student motivation, reading comprehension, effort level, and understanding of the material before attending class.

Related Reading on Flipped Classrooms: How to Increase Student Performance with Active Learning

Like what you’re learning? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

 

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Guided Discovery

F.I.S.G.R. Acroynm with "G" Highlighted to Represent Guided and Structured Discovery Questions

In my F.I.S.G.R. acronym, “G,” stands for guided and structured discovery. Some educational purists don’t like guided discovery, as they prefer students create their own learning needs based on a problem, and not be spoon fed questions to research.

I disagree with this approach. I’ve found the questions students generate are less sophisticated than one’s written by an expert in the field. My opinion is that questions written by faculty are more thoughtful, targeted and focused than those created by students.

 

Where should instructors ask guided discovery questions?

There are various places to do this inside a course:

  1. At the end of each chapter in the manual
  2. At the end of a case or a problem scenario
  3. At end of a video lecture recording
  4. In the faculty response to a reflective journal entry

Blackboard’s discussion board option allows students to respond to questions, upload their answers to case problems to a file exchange folder, and journal regarding what they see on observation practicums.

This is how it works in our classroom:

  1. Students respond to questions by opening the forum link in a Blackboard course.
  2. After students enter their answers, faculty and other students read the answers and comment on them.
  3. Once written, the answers are uploaded to the file exchange folder in Blackboard.
  4. In addition to writing and uploading their answers, students must present orally at a video conference.
  5. On observational practicums students are required to write reflections and respond to faculty comments in their journals.

 

Guided Discovery Question Examples

  1. Why do you think the TMJ is the only human joint that translates?
  2. If Posselt is correct and the mandible only rotates in the first 20 mm of opening, how would you get an early click?
  3. What is the main purpose of the other ligaments in the jaw (sphenomandibular, stylomandibular, TMJ ligament)?
  4. If Dr. Clark is correct and stretching of the lateral collateral ligament is what allows the disk to displace, how would this ligament become stretched?

 

Guided Discovery Questions for Patient Case Studies

Picture of a Dental X-Ray - Guided and Structured Discovery Questions for Patient Case Studies

When reviewing patient case studies, we recommend adding guided questions to deepen the student’s learning. For example, on the first few pages you’d have the medical questionnaire results, followed by the medical interview data, the physical exam data, photos and x-rays, and on the last page a set of questions for the student to research and report on. Here are some examples:

  1. Describe the growth pattern and site of growth in a normal TMJ.
  2. Research and report on the various surgical treatments used to treat unilateral condylar hyperplasia.
  3. Report on the article, Relationship between temporomandibular joint internal derangement and facial asymmetry in women, and do the conclusions of this article fit with this case?
  4. For this case, what additional diagnostic tests are needed and why?
  5. List the two or three most likely diagnoses (plus ICD-10 codes) that are appropriate in this case.
  6. What is your recommended treatment plan? Make sure you justify each element of your plan.

For examples of questions asked at the end of an interactive lecture, read our article on how to design an interactive course manual.

 

Do you encourage or demand participation?

You can do either but I require participation.  This means that faculty must also read, respond, and reward participation.

  • Make sure your guided questions are consistent with course learning outcomes.
  • Instructors should post the initial response to all discussion questions to establish presence.
  • Instructors should have a set of banked responses to post. Banked responses contain: thoughts on the topic, links to resources, or additional questions but all should be customized.
  • Reward great student posts with badge points, stars, or ribbons!

 

A Note on Using Reflective Journals

A Reflective Journal is where an individual student writes down their thoughts and faculty respond or comment on their thoughts. At a minimum the faculty should comment on the student’s writings weekly. You can grade journal entries or use them solely for communication and reflection.

Journals are great for pushing students to think deeper and learn more. While we do not use “reflective journals” for all courses, we do use them to document what the student learns on a observational practicum so they can capture their experiences. On the practicum the student will (hopefully) be exposed to new ideas and new ways of working.

This article, The Use of Journals in Legal Education: A Tool for Reflection, by J.P. Ogilvy describes that a reflective journal is a pedagogical tool worthy of more explicit attention by both clinical law teachers and non-clinical faculty alike. It introduces some of the literature on critical thinking and learning theory that supports the assignment of journals as an important tool in legal education.

This article also provides a starting point for articulating pedagogical goals that can be met through journal assignments, and it alerts the first-time user to the challenges inherent in the use of journals in legal education.

 

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Man in a Public Library Earning a Postgraduate Dentistry Degree Online

3 Best Practices for Creating an Interactive Course Manual

Man in a Public Library Earning a Postgraduate Dentistry Degree Online

There are several pieces of circumstantial evidence that exist to support the idea that students don’t read textbooks anymore. For example, Pearson, the largest publisher of educational textbooks has said they are phasing out print books and making all learning resources “digital first.” This isn’t definitive proof, but it is a strong piece of evidence.

If reading a print book is a dying behavior, who is to blame? The New York Times published an editorial, The iGen Shift: Colleges Are Changing to Reach the Next Generation, in 2018 claiming that Gen Z students rarely read print books, only digital media. In addition, in the Atlantic, a very respected magazine, there was even an editorial that declared the death of the textbook.

There are many research articles on this topic. For example, back in 2002, Sikorski, et al. reported that over 78% of freshman and sophomore students reported NOT reading the textbook at all, or reading it only sparingly, for at least one introductory course. There are others who have reported the same trend but I will spare you the review of these articles for now.

Related Reading: How to Increase Student Performance with Active Learning

 

3 Best Practices for Writing an Interactive e-Manual

S Stands for Supplement Lectures with an Interactive Course Manual - Online Teaching Strategies for Postgraduate Dentistry Programs

Fortunately, there are alternatives! Continuing our elaboration of the acronym F.I.S.G.R., we move to the next letter, “S,” which stands for the supplementation of your lectures (hopefully interactive lectures) with written content that also has interactivity.

Of course, maybe students won’t read this either, but if you make it essential and relevant to their goals (e.g. passing the course), they might! Here are some best practices worth considering when you create your own interactive course manual.

 

Best Practice 1.) Include a 30 second video intro to the course manual

On the first page of your course manual chapters, include instructions and a link to an introduction video to a video platform like YouTube. In a standalone document, the link to an introduction file (audio or video) is a good idea. However, if the chapter is associated with an actual video lecture you can omit an introductory audio file to avoid redundancy.

 

Best Practice 2.) Embed QR Codes

QR codes can be read by a smartphone with a free app, or if you have the latest iPhone, the camera detects and scans QR codes automatically. These QR codes link to a URL where an audio, video or even a 3D image file is available.

QR codes encourage students to look at the manual, and while viewing these supplemental materials don’t generate points automatically, you can let students know on the final exam that you’ll provide extra credit points if they viewed the materials.

 

What is gamification?

Wikipedia defines gamification as, “the application of game-design elements and game principles in non-game contexts.” In education, gamification means an instructor employs game design elements to improve user learning and reduce learner apathy.

One example of how we use gamification at the Herman Ostrow School of Dentistry of USC is through our Virtual Patient Game, which allows dental students opportunities to hone their diagnostic skills based on simulations of real-life patient case studies.

 

Play the Virtual Patient Game

 

A collection of research on gamification shows that a majority of studies on gamification find it has positive effects on individuals. The techniques used involve creating rewards for players who accomplish desired tasks or competitions to engage players.

Gamification Rewards

Types of rewards include points, achievement badges or achievement levels. Making the rewards for accomplishing tasks visible to other players or providing leaderboards are ways of encouraging players to compete.

Leaderboards in particular are used to rank players according to their relative success, measuring them against other users. However, the motivational potential of leaderboards is mixed. Most researchers regard leaderboards as effective motivators if there are only a few points left to the next level or position, but as demotivators if players find themselves at the bottom end of the leaderboard.

Higher education has used leaderboards for many years. For example honorable mention on the Dean’s list, the honor roll, and scholarships, which are equivalent to leveling-up a video game character.

 

Best Practice 3.) Use Thought-Provoking Questions

At the end of the lecture, handout, or course manual chapter, put in 3-4 deep questions that require the students to look at the suggested reading assignment and summarize what they learn on a class discussion board (usually in blackboard).

 

Example Questions:

  1. Do you think the characterizations that are given for Gen-Z are correct? Explain your answer!
  2. Do you think that the % of non-reading students decreases as you go up the academic ladder (i.e. do grad and professional students read more than B.S. degree or A.A. degree students)?
  3. Do you think it is unethical to “bribe” students with extra credit to read the manual by including polls and Easter eggs?

 

6 Things you Should Do to Create an Interactive eLearning Experience

Before we get to the six “dos” here’s one thing you mustn’t do when designing eLearning experiences: expect students will read your course manual or any other text-based supplemental materials just because you say it is good.

Here are six things we recommend you should do:

  1. Record an active learning lecture using TED talk format (~18 min)
  2. Regularly update content by checking Google and PubMed for new ideas, trends and even crazy stuff (must be evidence-based)
  3. Put links in your lectures to helpful, freely-accessible documents and media (e.g. YouTube, podcasts; Vlogs, recorded webinars)
  4. Embed questions and thoughtful discussion points inside your video
  5. Embed interactive content in a handout or online course manual
  6. Reward the students who interact with the embedded content with “bonus points”

 

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Female Dentist Earning a Postgraduate Dental Degree Online

How to Increase Student Performance with Active Learning

Female Dentist Earning a Postgraduate Dental Degree Online

In this installment of our series on effective online teaching, we will cover the basics of creating a recorded interactive lecture and an interactive course manual. In subsequent articles, we will explore the technology needed to do this.

Our goal is to go well beyond a simple video recording of an instructor talking to a class or a word document an instructor writes to supplement his or her course and then distributes to the students with a mandate to read it. Instead, I hope to show you how to create an interactive recording of your thoughts and a course document that student will want to watch and read.

When you really try to make your lecture content and your course manual an “interactive eLearning experience.” By the end of the course I hope you see that what you learn in this initial set of lectures can be applied to almost any situation where you want to teach someone in an asynchronous manner and yet keep them engaged and motivated.

Lectures Are Ineffective

The “lectures are ineffective” pronouncement comes from a variety of places, but the most convincing is an really thorough meta-analysis done in 2014 by Freeman and colleagues titled, Active learning increases student performance in science, engineering, and mathematics (PNAS June 10, 2014 111 (23) 8410-8415).

The study was a meta-analysis of 225 studies on teaching methods that used exam scores and failure rates from courses involved in STEM topics among undergraduates. The researchers compared lecturing and active learning styles, and analyzed the effect of class size for each method in each discipline.

Results:

  1. Effect sizes were significantly difference between 2 methods.
  2. Active learning had increase of 0.47 SDs on exams (n=158).
  3. Odds ratio for failing was 1.95 for traditional lecturing (n=67)

Active learning appears more effective overall but most effective in small (n ≤ 50) classes. This data raises the question about whether we should use traditional lecturing as a teaching methodology.

In other words, students in traditional lecture courses were 1.5X more likely to fail. In the graphic of the meta-analysis below, the data (B) shows that Active learning reduced failure rates by over 10%!

Chart Showing the Decrease in Failure Rate In Undergraduate STEM Courses in Classrooms that Use Active Learning

Effect sizes by discipline. (A) Data on examination scores, concept inventories, or other assessments. (B) Data on failure rates. Numbers below data points indicate the number of independent studies; horizontal lines are 95% confidence intervals.

Using a Flipped Classroom for Active Learning

The Freeman et al article essentially offers a suggestion on what to do, namely engage in Active Learning! An excellent example of a School that followed up on this idea comes from the Vermont Medical School (UVM). This school choose to eliminate all lectures and now only uses active learning style educational methods for their medical student classes.

The faculty at UVM create an active learning classroom environment by using a flipped classroom. Students learn about the subject before they get there, and in class they work in groups solving problems. You remember better and longer the problems you solve!

In large classes (~100 people) students are broken up in to groups of about 6 students and they are given a task to work on based on material that was sent to the students before they assembled for this class. There is usually only one or two faculty in the course. Of course, medical students are among the most competitive and therefore probably compliant to what the instructor is asking of them. This approach may not work as well in other setting with other students and more faculty may be needed.

Since many of us have transitioned to teaching online right now, Zoom Breakout Rooms are a great way to use a flipped classroom approach and guide group problem-solving in a digital-first classroom.

How to Teach Interactively

F is for Focused Lectures - Online Teaching Strategies for Postgraduate Dentistry Program and Teledentistry

In a recent article we explained five steps to teaching online effectively. The first letter, “F,” stands for “focused, short, up to date lecture.” I know I said they were dead, but give me a little time to explain what interactive eLearning experiences are and are not!

Reduce Cognitive Overload

The reason why 50 or 60-minute powerpoint-based lectures don’t work well is because of “cognitive overload.” In the early 1980s, researchers found that people suffer from cognitive overload, and is the basis for why “TED Talks” have a maximum length of 18 minutes.

Simply put, information acts like weights: the more you pile on, the more likely you are to drop everything. A 5-minute microlearning lecture produces a relatively small amount of cognitive backlog, while a 30-minute lecture produces a relatively large amount.

Now, recording a lecture does not make it inherently better than a standard lecture, but if you make it interactive you engage every student (which can’t be done in a large lecture hall), and it is certainly more convenient for the students to view! When you create lecture recordings there are some things you should and shouldn’t do.

Asynchronous Interactive lectures should not have links to external materials that are broken or quiz questions/hotspots that are not relevant to the topic. Asynchronous Interactive lectures should have links to some of the massive freely accessible documents and media (YouTube; Podcasts; Vlogs; Recorded Webinars) and pop-up questions that reinforce what the student really needs to know.

Finally it is suggested that you include a set of deep thought questions for discussion at follow-up video conference! Examples below!

Recap: 4 Ways to Create Interactive eLearning Experiences

  1. Record an active learning lecture using TED talk format (~18 min)
  2. Regularly update content by checking google and pub-med for new ideas, trends and even crazy stuff (must be evidence based)
  3. Put links in your lectures to helpful, freely-accessible documents and media (e.g. YouTube, podcasts; Vlogs, recorded webinars)
  4. Embed questions and thoughtful discussion points inside your video

Examples of Embedded eLearning Questions

I typically ask students to summarize (no more than 300 words) what they learn from the resource I suggest and post them to the Blackboard Discussion Board. The best responses look at more than the single suggested resource to formulate your answer! Students are awarded bonus points for good comments on other student’s reflections.

  • Read and summarize what exactly is cognitive overload and does it differ for different age groups?
  • Read and summarize why the Freeman paper was controversial? Did anyone dispute these results and what was their argument?
  • Read and summarize follow-ups to the Vermont Medical School lecture dropping experiment (i.e. does it work)?

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Teledentistry - Frequently Asked Questions - Female Dentist Conducting a Telehealth Consultation

Teledentistry – Frequently Asked Questions

Teledentistry - Frequently Asked Questions - Female Dentist Conducting a Telehealth Consultation

These FAQs were collected from a recent webinar on Telehealth & COVID-19 presented by the Herman Ostrow School of Dentistry with Dr. Glenn Clark, Professor Linda Brookman, Dr. Kamal Aleryani, and Dr. Steven Richeimer.

 

 

What is Teledentistry in 2020?

“Teledentistry” is obviously seeing patients via either a phone or internet video connection. Teledentistry is primarily used for consulting with potential new patients, reviewing results of treatment from PORs, and for emergency patients. Teledentistry can be over the phone, video, text, and it can be synchronous or asynchronous.

Telehealth typically includes some form of branched, smart questionnaire, a predictive diagnosis based on data mining and predictive values, a self-exam or clinical exam to identify features related to each identified condition, and a diagnosis and treatment plan based on evidence-based protocols.

In 2000, I was a guest editor of the California Dental Association Journal. I invited a group of collegues to contribute to the edition. A lawyer, a futurist, an oral medicine specialist, a community health specialist. Yes, it was 20 years ago that I put together this series of articles! BTW: don’t ever go back and read what you wrote 20 years ago, unless you want to see how naïve you were about a topic.

 

Is Teledentistry legal?

It is legal in “most states”. When it isn’t legal, you can’t charge for it. Because policies and laws are constantly changing, be sure to stay connected with your state’s governing boards. If you’re curious, start with the ADA’s statement on Teledentistry and if you practice in California, read this article on California’s Teledentistry requirements.

 

Can Teleconsulting for oral disease be performed and is it accurate?

Yes, it can be performed and yes it is accurate, depending on the question being asked. Some issues you can’t solve without additional information (e.g. intraoral camera, radiographs or biopsy). Some can be solved.

 

Accuracy of Teledentistry for Diagnosing Dental Pathology

Outcome Evaluable, n (%) Sensitivity (95% CI) Specificity (95% CI)
Main outcome
 Dental pathology 231 (98.3) 93.8% (90.7%–96.9%) 94.2% (91.2%–97.2%)
Secondary outcomes
 Chewing ability 198 (84.3) 85.0% (80.0%–90.0%) 82.8% (77.5%–88.1%)
 Dental prostheses rehabilitation success 144 (61.3) 87.8% (82.5%–93.1%) 90.3% (85.5%–95.1%)

Queyroux A, et al. Accuracy of Teledentistry for Diagnosing Dental Pathology Using Direct Examination as a Gold Standard: Results of the Tel-e-dent Study of Older Adults Living in Nursing Homes. J Am Med Dir Assoc. 2017 Jun 1;18(6):528-532.

The researchers in France had a caregiver at the nursing home perform a video oral examination of the patient and sent it to the expert who was not physically present. Currently, intraoral video cameras are just a little more expensive than an electric toothbrush, so they can be readily available at the patients location.

 

Which healthcare areas (including dentistry) are best suited for Telehealth?

Many are suited some are not, but certainly Pain Medicine and Orofacial Pain are great fits; I’d like to think Oral Medicine diseases (that are visible) is another good fit!

Currently, the Center for Medicare and Medicaid has listed only physicians, nurses and physician assistants as legitimate Medicare and Medicaid Telehealth providers. Unless this changes, dentists, physical therapists, occupational therapists, and chiropractors are blocked from seeing these patients via a telehealth consult.

 

If you are a Medicare provider but not one of the approved providers, can you see a medicare patient and directly charge them a fee for your service?

There is an Advanced Beneficiary Notice  (ABN) of non-coverage form CMS-R-131, but it is simpler as a dentist to opt-out of medicare! It appears that when you look at the existing telehealth services the average consult is 15 minutes and the average fee is $79 for this.

 

How much time should you spend for a teleconsult with a chronic pain patient (whose story might be longer and more complex than a primary care patient)?

Of course, it will depend on the patient and the nature of their problem. We estimate 20 minutes for actual consult, another 10 minutes to make careful notes. This however, assumes that the patient has filled out a detailed pre-encounter questionnaire.  A pre-encounter questionnaire might include basic demographic information, location, visit details, symptoms, and causation.

 

What do Medicare and Medicaid pay for a teleconsult (assuming you are an approved provider) and what level of documentation is needed?

This is yet to be seen. Physicians think they will get paid the same as when they see the patient in person. I doubt this and if the payments are increased for awhile, this probably won’t last.

 

I see there are networks you can join as a healthcare provider. What is the advantage of this?

Mostly the national telehealth services provide very brief consults (mostly informational) and are probably better thought of as potential “practice builders.” While I don’t have data on what dentists earn on such website services, I don’t think they’re a way to earn a living.

 

Average Pay to MD’s for Telemedicine

  • Typically telemedicine pays per consult or per hour
  • Most telehealth contractors are part-time
  • Telemedicine physicians average $15-30/visit
  • You set up direct deposit about every 2 wks
  • Visits are typically 5-10 minutes
  • Asynchronous telemedicine is text-based
  • Asynchronous visits pay per inbox message
  • Asynchronous telemedicine pays $8-18/consult

Source: https://www.wheel.com/blog/telemedicine-compensation-guide-tips-for-making-money/

Here are three teledentistry services. I don’t endorse or reject any of them:

 

Must the patient be located in the state you are licensed in and are there any exceptions to this rule?

Yes, absolutely they must be in the same state! One exception is the PT license compact, which allow Physical Therapists to practice across state lines. This type of relaxation of state lines does not exist for dentists.

There are a several ways to find geolocation of a user: HTML5 API, Cell Signal and IP Address to name a few. Pairing of IP address to a geographical location is the method we used to provide geolocation data. There are times when you need to identify where your web visitors are coming from.

 

The American Telemedicine Association

“In the latest policy update, the ATA outlines several actions Governors can take immediately to facilitate the use of telehealth and safely expand virtual care during the COVID-19 public health emergency. As of March 24, 2020, more than twenty-five states have waived licensure requirements to leverage telehealth to fill provider shortages and ensure access to care”

Those 25 states include: Alabama, Arizona, Connecticut, Colorado, Delaware, Florida, Georgia, Kansas, Idaho, Indiana, Iowa, Maryland, Massachusetts, Mississippi, Montana, New Hampshire, New Jersey, New York, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah.

Unfortunately, California is still missing from this list.

 

Must the same insurance documentation standards (e.g. Medicare H&E) be met?

Yes, absolutely! The figure below is familiar to anyone who takes medicare, which most dentists don’t. It shows the type of data that must be collected to charge medicare.

 

Required Main Elements to Meet Criteria for E/M Levels (2/3)

E/M CodeHPI (# elements)ROS (# systems)PFSHExam (# elements)MDM
992121-3001-5straightforward
992131-310≥ 6low
99214≥ 421≥ 9moderate

NOTE: HPI, ROS, and PFSH together make up the “history” main element, and only 2/3 of history, exam, and MDM are needed.

 

I assume that malpractice insurance is still in place and covers you even when you have never physically seen a patient if they sue you?

Yes, I  hope! Please call your state board and your malpractice provider to be sure.

 

Are we going to be required to record and store audio inter-actions within a teleconsult in the cloud somewhere?

No, just make good notes in your patient record.

 

If you wanted to record your teleconsult in a cloud do you need anything more than verbal consent from the patient?

No, but they must know that this is riskier for HIPAA!

 

When you initiate a teleconsult with a new patient are they now a patient of record and what are your responsibilities to the POR?

Yes, but if your terms of service are clear, you can limit your responsibilities, but make sure the patient agrees to the service limitation. Below is just an example of limited service, liability and indemnity for a telemedicine service encounter.

 

Example: Limitations of Liability and Indemnity for Expert Content.

Informational content on the Apps that is created, modified, submitted, or validated by Medical Experts or other healthcare experts (collectively, “Expert Content”) is subject to the following additional terms and conditions and agreements by You. Expert Content is for informational purposes only. For medical advice, treatment, or diagnosis, see your personal doctor or healthcare provider.

 

Can you prescribe a medication or other treatment based on a teleconsult only?

Yes, absolutely, but you need to get adequate medical information and please avoid prescribing controlled substances.

 

What video consult system should you use to conduct a teleconsult?

Zoom is pretty good and easy to use and low cost and HIPAA compliant!

 

How do you collect money for a teleconsult?

Collect the money before the consult! I recommend the following patient workflow:

  1. Submit request through an online form
  2. Submit payment
  3. Schedule appointment
  4. Conduct consultation

For payment, I suggest an event billing service like Eventbrite, Venmo, or Paypal, but unfortunately they cost between 2-8%.

 

How do you phone patients without giving them your private cell phone number?

I suggest using Google Voice but also get G-suite to make it HIPAA compliant.

 

What do you need on your website to get your teleconsulting service running?

Here’s what you need:

  • A request form for televisit
  • A PHI disclaimer (for request form)
  • A terms of service explanation
  • A teleconsultation explanation
  • A good symptom questionnaire
  • A payment policy statement
  • A Disclaimer & Telehealth consent

 

Example PHI Disclaimer

Information collected from this website or provided on any form you have submitted through the website is used only in conjunction with an interest by the user in obtaining additional information from the Herman Ostrow School of Dentistry Orofacial Pain and Oral Medicine Center. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested that you be contacted. In addition, information provided on the website or in any response to you is not and cannot be considered medical advice or treatment.

 

Terms of Service Explanation

At the Orofacial Pain and Oral Medicine Center, we provide a wide range of oral healthcare services to patients treating painful condition and other oral diseases affecting the orofacial region. All services are done by residents under the supervision of our expert faculty. Since we are a teaching institution and care is delivered in an instructional environment.

 

Teleconsultation Explanation

The Orofacial Pain and Oral Medicine Center uses teleconsultation as a way to help our patients of record with their care. We also will take appointments for new patients, who live in California. At the first visit of a new patient we will take information from the patient … See more on OFPOM Center’s website.

 

Paying for Your Dental Care Policy

The care and expertise of USC faculty dentists is within reach and our faculty dentists charge fees commensurate with private dental practices in the region. We accept some medical insurances but not all. Payment is expected for all services at the time services are rendered. We accept cash, checks, money orders and credit cards (Visa, MasterCard, American Express and Discover).

 

Telehealth Informed Consent 

  1. I understand that I am going to engage in a telemedicine consultation.
  2. I understand that I have the right to schedule a physical visit to the OFPOM Center for consultation, and I am choosing to participate in a telemedicine consultation.
  3. I understand that telemedicine consultation will not be the same as a direct patient/healthcare provider visit because I will not be in the same room with my healthcare provider.
  4. I understand that my healthcare provider will not be able to do a physical exam on me as we are in the same room, and any physical examination may be self-examine under the direction of the consulting healthcare provider.
  5. I understand that my counselor might ask for additional diagnostic exams that require a traditional OFPOM Center visit.
  6. I understand that treatments that require surgical or any other type of physical intervention can not be done online, and a traditional visit is needed to be performed.
  7. I understand that if I decided to withdraw from the online consultation, that would not affect my right to schedule a regular visit at the OFPOM Center.
  8. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine.
  9. I understand that an appointment delay in medical evaluation and treatment could occur due to failures of the telemedicine equipment (Internet, Computer, etc.)
  10. I understand that I have the right to ask for a copy of this telemedicine consultation.
  11. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
  12. I attest that I am located in the state of California and will be present in the state of California during all my telemedicine consultations with OFPOM Center.
  13. I understand that I will be responsible for any payment for this telemedicine consultation.
  14. I agree with the above Telehealth Informed Consent.

 

Where can I get more information?

Visit our blog, Orofacial Pain and Oral Medicine Center Website, and check back here for updates as we put more material together

 

Online Postgraduate Degrees in Orofacial Pain and Oral Medicine

Do you want to deliver appropriate and safe care to your growing and aging dental patients? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine.

 

Get More Information

 

Tips for Interactive Teaching Online Dental School

How to Teach Online Courses Effectively

5 Tips for Effective Teaching Online Postgraduate Dental Programs - Focused, Interactive, Supplemental, Guided Discovery, and Rewards

I recommend five things that you should consider using if you want to teach interactively: focused lectures, interactive teaching, supplementation, guided and structured discovery, and rewards (F.I.S.G.R.)

1. Focused, Short, Up-to-Date Lectures

The first letter is “F” and it stand for focused, short, up-to-date lectures. When we say lectures, let’s explain what interactive e-learning experiences are and are not. They are not tedious 1-hour long, one-way lectures, they don’t use outdated materials or ideas and it does not, within reason, fail to comment on new ideas that students want to know about.

It is a brief (18 minutes max.) presentation that has been updated with discussion of new trends while maintaining the educator’s golden rule: “what you teach has to be evidence based!”

2. Interactive Teaching

In a face-to-face (F2F) classroom, you should engage the student in the class by asking individual students a question at different points in the lecture. If you don’t like potentially embarrassing a student you can use a “clickers” or now smartphones to have all the students vote on questions they pose during the class. The results are displayed on the screen and it keeps the student engaged with the lecturer.

In an asynchronous recorded lecture, you can do this also by embedding polls and questions inside the lecture recording. Another way to interact with students is to give them a set of more thoughtful questions that they would have to research and then respond to in writing on a web-based discussion board.

Here are four things I recommend when developing interactive teaching content:

  1. Record an active learning lecture using TED talk format (~18 min)
  2. Regularly update content by checking google and pub-med for new ideas, trends and even crazy stuff (must be evidence based)
  3. Put links in your lectures to helpful, freely-accessible documents and media (e.g. YouTube, podcasts; vlogs, recorded webinars)
  4. Embed questions and thoughtful discussion points inside your video

3. Supplementation

“S” stands for supplementation of your lectures (hopefully interactive) with written content that also has interactivity. Of course, maybe students won’t read this either, but if you make it essential and relevant to their goals (e.g. passing the course), they might!

One such example of supplementation is gamification to improve user learning and reduce learner apathy. One example of how we use gamification at the Herman Ostrow School of Dentistry of USC is through our Virtual Patient Game, which allows dental students opportunities to hone their diagnostic skills based on simulations of real-life patient case studies.

 

Play the Virtual Patient Game

 

4. Guided and Structured Discovery

Some educational purists don’t like guided and structured discovery, as they prefer that the students create their own learning needs based on a problem, and not be spoon fed questions to research.

I would disagree with this approach as I have found that without structure, the questions students generate are less sophisticated than one’s written by an expert in the field. My opinion is that the questions written by the faculty are usually more thoughtful, targeted and focused than those created by the students so I prefer guided and structured discovery over student generated learning needs.

5. Rewards

In general, the principle is that rewards motivate students. Milestones mark a student’s growth or progress towards the ultimate goal. EPAs are relatively new on the residency training scene. EPA stands for Entrustable Professional Activities. Completing an EPA and being certified as completing it is critical in the education of both medical and dental residents.

EPAs are used to determine when a resident (medical or dental can be indirectly supervised as opposed to directly supervised. This is an important distinction since direct supervision requires the attending faculty be present when a resident works with a patient but indirect supervision does not!

Stay tuned for more posts as we explore each of these topics in depth with examples and practical tips make your online teaching experience more effective and interactive for students.

Online Postgraduate Dental Degrees in Orofacial Pain and Oral Medicine

Do you want to deliver appropriate and safe care to your growing and aging dental patients? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine.

 

Get More Information