Eur J Dent Educ 2001; 5: 93–100 Copyright C Munksgaard 2001

Printed in Denmark. All rights reserved

ISSN 1396-5883

Review Article

Computer assisted learning. A Review

Martin Schittek1, Nikos Mattheos1, H. C. Lyon2 and Rolf Attström1,3
1
Department of Periodontology, Centre for Oral Health Sciences, Malmö University, Malmö, Sweden; 2Professor of Health Science, Notre Dame College,
Manchester, NH USA. Fullbright Professor of Medical Education and Informatics, Ludwig Maximilians University, Munich, Germany; 3Department
of Periodontology and Fixed Prosthodontics, School of Dental Medicine, University of Berne, Berne, Switzerland

Since 1980 the amount of medical information has doubled ap- puter literacy is still low. New authoring tools make it easier for
proximately every second year. This implies that oral health stu- faculties to develop their own CAL software. In the future we will
dents as well as professionals need to manage the flow of infor- see more sophisticated software with virtual patients who can
mation rationally, in order to learn how to undertake evidence- communicate and interact with the student in a very realistic way.
based decision-making for diagnosis and treatment in a given The software will even ‘‘step out’’ from the screen and help the
patient situation. Current research indicates that computer con- student with clinical procedures. However, at present CAL should
nected databases and computer assisted learning (CAL) may not replace traditional education, but rather be used more as a
enhance learning and provide the clinician with information for supplement and for self-directed studies.
decision-making when treating patients. Multimedia for CAL,
which combines audio and visual data in an interactive form, has
proved to be an effective tool in education. CAL may supplement Key words: computer assisted learning; computer aided learn-
and reinforce more traditional learning and create opportunities ing; computer aided instruction; health education; effectiveness
to illustrate clinical situations in an interactive way. CAL has the of learning.
potential to help students develop skills and knowledge. Stu-
dents, staff and professionals consider CAL stimulating and mo- c Munksgaard, 2001
tivating. Students easily adapt to CAL although their current com- Accepted for publication 7 November 2000

C OMPUTER Assisted Learning (CAL) has been a

term of increasing significance during the last
decade and can also be referred to as Computer Based
Computer mediated human-human interaction is a
whole new area in CAL, which presents special meth-
odological considerations and requires separate study
Instruction (CBI), Computer Aided Learning (CAL), (3).
or Computer Aided Instruction (CAI) (1). For the pur- The present review will be focused on CAL appli-
pose of this review, we can simply define CAL as the cations where interaction is limited between the user
learning procedures and environments facilitated and the content, as the educational experience with
through computers. However, the keyword for under- these applications is wider, and their future prospects
standing CAL is interaction. Computers can facilitate are also remarkable. These CAL applications were ini-
interaction during the learning process on multiple tially designed for local use as part of the traditional
levels. On one level we have interaction of the stu- curriculum. However as both technology and educa-
dent/user with the content and the learning material tional experience mature, the real potential of these
(for example with an interactive patient on a CD- programs unfolds in distance learning. It is important
ROM). On another level, computers can host interac- to remark that although interactive CAL programs are
tion of the student/user with the tutor, peer interac- accessed from different places, they are directed by
tion or interaction between members of whole ‘‘vir- the same educational principles. For instance an
tual’’ learning communities. ‘‘interactive patient’’ can be accessed through a CD-
The concept of interaction with content was first in- ROM in the university ICT lab supplementing the lo-
troduced in applications as early as the 1980’s and is cal curriculum, and the same application can be avail-
probably the best studied aspect of CAL (2). Com- able on the web as part of a distance learning course.
puters’ facilitation of interaction between humans, In both cases, the learning principles and methodolog-
however, has only emerged during the last decade, ical implications are identical, as long as the interac-
as explosive technological progress and the Internet tion remains between the user and the content. There-
allowed reliable and inexpensive communication. fore study of this kind of application even if in a local

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Schittek et al.

environment, is directly applicable to the use of CAL be made with colleagues and resource persons in spite
in distance learning, where the future of the medium of geographical restrictions (9, 10).
undoubtedly lies. The Internet already hosts an increasing variety of
The present study aims to summarise the current programs and databases, making them available for
experience in the field of CAL applications in health effective and inexpensive distance learning to all
education. The review is particularly focused on kinds of dental students and professionals (11). From
educational value of CAL, as well as its effectiveness on-line tutorials and tests to case studies, simulations
in comparison to traditional teaching. In addition, we and interactive patients (12, 13), the ever-increasing
intend to investigate the attitude towards CAL among number of available CAL applications on Internet has
the students, staff and professionals. Finally, visible already shaped the future of the medium in oral
future trends and developments in the field will be health education. In addition, recent software and
presented. web design tools allow content experts to design high
quality multimedia CAL packages, without the need
of expensive technology or technical expertise. These
A brief historic review
developments are expected to boost CAL production
In the 1950s computer use was introduced in edu- even further. Therefore, evidence-based study and re-
cation. At that time multimedia did not exist as we search on CAL in dental education and the relevant
known it today. Interaction with computers was avail- educational and methodological implications are ur-
able by means of slides and audiotapes. The computer gently needed, if we are to utilize the full potential of
mainframe was connected with terminals that were the medium.
placed relatively far away from the main computer.
The computer was used as a knowledge-bank of ques-
tions by which students could undertake self-assess-
ment of their knowledge (4). In the early 1970s the use
CAL in dentistry
of computers increased. The mainframes were very Current CAL software in dentistry
expensive and difficult to use. It was not until august Learning
1981, when IBM presented the microcomputer IBM CAL provides an effective way of learning. The pro-
PC (personal computer) that the use of computers for gram in the computer guides the student through an
educational purpose started to develop. Reports in the interactive document that integrates text, 2D- as well
British Dental Journal were optimistic regarding the as 3D-images, video, sound, animation and individual
computer’s future role in dental education and in the interactions. The student is able either to follow a
dental clinic (5). given path or to design his individual path within the
One of the first CAL programs in dentistry was de- learning material, according to his own learning ob-
veloped by Luffingham in 1984. He used an Apple II jectives. Many of the programs place the student in an
48K PC to control a videotape and allow students to interactive role as a diagnostic dentist. The program
answer simple multiple-choice questions. His con- evaluates the student’s diagnosis depending on what
clusion from this study was that CAL provided the facts have been accessed (9, 14–16). Some of the pro-
student with a popular and effective way of learning grams are built on to the principles of the Problem
(6). Computers have been used in clinical practice for Based Learning (PBL) system (17).
about 15 years. In spite of this, few dental faculties There are a wide variety of CAL programs available
have appropriately prepared the students for using on the market, ranging from very simple to advanced.
programs and applications that are available for den- Many of the programs have been scientifically evalu-
tal clinics (7). There are today a number of CAL pro- ated with varying results. Most aim at diagnosis and
grams available on the market. However it seems that decision-making. Evaluated packages are available in
the development of CAL is based on the work of very some of the following subjects:
few individuals rather than being a part of the fac- O Anatomy (1)
ulty’s ICT strategies (8). O Radiology (4, 18)
The recent progress of communication technology O Orthodontics (6, 19)
and the wide introduction of the Internet have added O Prosthodontics (9, 20)
a whole new dimension to CAL. Tools to gather infor- O Periodontology (21)
mation through the Internet provide great opportun- O Implantology (22)
ities for searching literature and establishing fast com- O Endodontics (14, 16)
munication with international resources. Contacts can O Trauma (23)

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O Cariology (9, 24) students self-assessed their general computer knowl-

O Taking a biopsy (19) edge with a mean score of 1.85 on a 1–5 graded scale.
O Pathology (25) The same students rated the value of computers in
Teaching students how to chart teeth offers a simple dental care with a mean score of 3.91 (7). In a study
example of the practical use of CAL. Students have from 1994, 63% classified their computer literacy as
problems with the reversal of right and left sides in negligible or reduced. Of the same students, 85%
the mouth when moving the information into charts. thought that computers are important in medicine
A program was developed in which the student could (27). Another study from 1999 showed that 51.1% con-
look at pictures with lesions and then practise putting sidered their expertise with computers as ‘‘poor’’ (28).
the results in an electronic record. The evaluation These observations point out that students realise the
showed that the students who had used the com- importance of computers in the dental field. Thus,
puterised education had 80% better results in pre- and even if computers are more common today, computer
post-tests compared with only 39% in the control literacy among students is still low.
group (24).
Pre-clinical education can also be accomplished by Staff considerations
using computers. Existing software can teach prepara- Even teachers thought that CAL was stimulating.
tion of teeth for fillings and crowns. The computer However, the low answer frequency (less then 50%)
program follows the student’s preparation while it is on the questionnaire could indicate that not all
in progress, reproducing it afterwards in a 3D-image. teachers think that CAL is an important issue (8, 29).
This 3D-image is used to study different aspects of the It appears that there is a silent majority of teachers,
student’s accomplished work (9). whose opinion is not reflected in relevant surveys as
they are not interested or competent in the medium
Examination (8).
Recently, efforts have been made to use computers in
examinations. There are a few programs available on Professional considerations
the market for examinations. Few scientific studies The clinician’s acceptance of CAL has been evaluated
have been conducted in the field of examination in in program packages in different dental subjects. The
health care education. Only some applications are software received good assessments compared to
found in the literature (18). These programs often use tapes, books or journals (19, 20, 22). An extensive
multiple-choice questions as a test. evaluation of CAL packages in Britain, undertaken
from 1992 until 1998, demonstrated perceived levels
of knowledge gain from 70% to 88% among users. The
Attitudes towards CAL perceived level of skills acquisition however was,
Student considerations shown to be between 20% and 57% (30).
Survey studies conducted during the 1980s, demon-
strate significantly different results than those made
during the 1990s. In the 80s students considered CAL Effects of CAL in academic education
to offer an advantage and be time-saving in compari- Learning
son to more traditional education (4, 25). In the 90s Several studies have shown that groups of students
the students were significantly more positive and who are using CAL have better results than groups
used computers more for learning purposes than they using traditional learning (8, 9, 14, 24, 31). Some studies
did earlier (4). Studies at dental faculties in two conti- even demonstrate that students using CAL needed
nents have confirmed that the majority of students shorter time to reach the learning objectives, achieving
consider CAL challenging and motivating. better final results then students who did not have ac-
Even students who have no experience with com- cess to CAL (14, 32). Generally it seems that the more
puters adapt easily to CAL software (4, 26). Those stu- recent a study is, the better are its results. References
dents who have computer experience have a greater from the 80s show that CAL is as good as traditional
belief that CAL can replace lectures (26). education (16, 33), while later references indicate that
However, very few dental students have tried mul- CAL is better than traditional education (8, 14, 16, 24,
timedia software with animations during their edu- 31, 33–36,). This could reflect the fact that computers
cation (8). This may be because many students today have lately become better in graphics, usability, multi-
have insufficient computer knowledge and don’t feel media etc. However, Clark reports that there are biases
comfortable with computers. In a study from 1992, in many technology-focused papers. Even those with

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poor controls show the computer to be superior to tra-

ditional teaching (37).
CAL versus traditional dental education
An interesting finding is that students with learning CAL versus books and lectures
difficulties sometimes significantly improve their When a case is presented in a book, all the learning
learning using CAL compared to stronger students. material is presented linearly, frequently together
By using CAL the former catch up with the latter (10). with a subsequent solution to the case. Often the book
The communication between students and teachers begins from an already given topic with a description
generally increases (36), which may provide more shy of a patient record and status for the cases. This prin-
students with a better chance to verbalise their ciple is also frequently used in lectures: usually the
thoughts. Those students who have used computers student gets the solution without any interaction with
in their education seem to be more active and focused the teacher or content. In CAL the symptoms are pre-
than those who have only been exposed to traditional sented for a given patient case. The student is put in
education (31). Other studies demonstrate similar re- the role of a professional making a diagnosis for a
sults. Kulik et al. (1991) carried out a meta-analysis of patient. The student can ask the computer for infor-
254 controlled studies, finding that CAL usually had mation relevant to the case. The student suggests a
a positive effect on students. Their scores increased diagnosis/treatment and the computer indicates how
by an average of 0.30 standard deviations, which was well the student has solved the task. Student com-
coupled with a small but positive change in students’ ments on the chosen selection can be put into a data-
attitudes and a substantial reduction in the amount of base containing the patient records.
time required for instruction. The authors indicate Traditional book and lecture teaching represents a
that they consider this effect to be significant (38). one-way communication with the student. Neither of
Jelovsek et al. (39) examined 49 ‘‘clinical’’ trials these resources often stimulates the student. This im-
comparing CAL with conventional methods of learn- plies that there is limited possibility for interaction
ing. The authors focused on studying cognitive out- with the resources. CAL, on the other hand, stimu-
come, behaviour and learning theory, using students, lates the student to interactive learning by providing
doctors and patients as learners. The results were: the possibility for interaction with the media, at a per-
O In performance terms, CAL was as good as conven- sonally chosen level. For instance, many of the pro-
tional learning in 98% of the trials. grams often demand that the student ask for relevant
O CAL showed an improvement between pre-test information about the current situation in order to be
and post-test scores over conventional methods in able to continue. CAL also provides the student with
61% of the studies. the opportunity to go through the material at his own
O Generally learners with CAL took about the same pace and repeat chosen parts, without involving a
amount of time to achieve a better overall perform- teacher or other students. CAL is especially valuable
ance, though a small number of studies indicated when the program contains possibilities of direct con-
that more time was taken to achieve a better per- tact with on-site teachers.
formance (because of motivation).
O CAL required much less time to achieve the same The students’ learning style
performance. Students want to achieve as good assessments and
grades as possible. Because of this, students are
Examination usually strategic and use different kinds of learning
Only a few studies have been carried out in the field approaches to different courses, often in sophisticated
of computer-assisted test/examination (CAT) in the ways. One important factor is the design of the exam.
field of health science. Depending on the examination form, students employ
One study regarding time-consumption in examina- different learning styles (42). Additionally, when the
tion using computers showed that CAT required the time for examination is approaching, students often
same amount of time as traditional multiple-choice pass from a deeper understanding of the content to a
examination (14). Studies from other academic fields pure memorising mode (43).
present similar results (40). Even those students who Students’ learning strategies are often content-de-
didn’t have any computer experience preferred CAT pendent (44). There is sometimes a strong correlation
to traditional paper and pen tests (40). Yet some between the quantity of necessary activity and the
psychological tests and exams show that CAT can quality of learning. The more that is demanded from
have negative effects on the results of those not fam- students, the more likely they will adapt a superficial
iliar with computers (41). learning style (45). In a study done on Nordic dental

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faculties, many students (54%–77%) thought they had Other advantages of CAL:
little time available for studying. The students also O The computer is very patient and has time.
considered that the teachers had deficient teaching O The computer is not judgmental if the student
skills. Many students felt that teaching was a second makes a mistake. The student ‘‘dares to answer’’
priority for the teachers (46). One reason for negative the computer’s question without risking feeling
student attitudes is that sometimes the teaching staff stupid if he provides the wrong answers.
in universities have had limited pedagogic education. O CAL can be repeated frequently without the com-
Students usually wish for more factual and concrete puter ‘‘getting tired’’ or impatient.
information, a more structured curriculum and organ-
ised conditions (42, 43). In other words, things should
Future trends
not be left to chance. One of the most popular learning
resources is teacher handouts (33, 43). Even small Learning
changes in how the information is presented can lead The production of CAL packages in dentistry has in-
to major alterations in learning outcomes (47). creased remarkably during the last 5 years. As new
authoring tools became available at a low cost, an in-
The computer’s teaching style creasing number of institutions and individuals are
Research results show that if an image is initially blur- now involved in design and production of CAL appli-
ry, and then becomes clear, it is remembered much cations. This has increased both the variety and the
better than if it is presented clearly for the same quality of CAL applications, while at the same time
amount of time. This could mean that if an image lowering all costs related to production and use. The
were to be drawn instead of being instantly presented, Internet can now serve as a universal database of
learners might remember it better. It has also been CAL, which is available to a global audience, in many
shown that learners have an ability to remember ani- cases free of charge. It is interesting to note that 50%
mations well (47). Interactive multimedia software en- of British dentists would be willing to pay £50 for a
gages students in decision-making and multi-sensory CAL package in 1993, while this percentage was
learning. When all senses are stimulated, learning will lowered to 37% in 1995 and only 5% in 1998 (30). This
be most effective and the student more interested (9). clearly demonstrates the effects of the Internet and the
It has even been shown that if the computer grants wide variety of choice that the CAL user has today. In
the student an award (e.g. in form of an animated the near future, dentists and dental students will have
writing of his name), the student will try to perform access to an enormous number of applications, which
better (47). will also push the quality criteria and demands of the
A book can never provide or teach active dental users even further. The only visible obstacles to utilis-
therapy planning. To facilitate this kind of learning, ing this media will be the still insufficient computer
real patients and training are required. A computer skills of students and professionals and the lack of
can, in a very realistic way, simulate real patients. To research evidence concerning several methodological
be able to go farther in a patient simulation program, implications of CAL.
the student has to ask for relevant information about Apart from purely educational applications, com-
the case. This demands that the student be attentive puters have been used in several other areas of dental
and concentrate, which provides conditions for good care. Digital image management, for example, in ortho-
learning (47). dontic KEF calculations and digital X-rays represent
Students willingly use sophisticated instruments for some very important applications of computers in Or-
learning (8). In addition, if they participate in the de- thodontics. In addition, the CAD/CAM technique is
velopment of the software, they will become more widely applied in restorative dentistry (23). If these re-
motivated to use it (4). Software that is developed by sources were connected to a database containing all
the faculty contains structured, actual and concrete in- pre- and post-treatment images, information, and re-
formation and is more likely to contain exam-relevant sults, a large knowledge-bank would be created. From
material. Since students adapt a learning style which this, different treatments could be evaluated.
favours the exam results when practising cases, they ICT would be of a great help for patients, not only
will be more motivated to use this software (42, 43, directly, but also by providing the clinician with fast
47). The software is designed in a way that ‘‘forces’’ access to updated information which could later be
the student to think and concentrate toward the fac- used as a support for clinical decision-making (34).
ulty learning objectives, thus stimulating deeper In preclinical teaching, virtual reality and force-
thinking. feedback technology will make it possible to simulate

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Fig. 1. Graphic illustration of the process when using computer assisted examination procedures in treatment planning

and practise clinical situations in a realistic way with- O Sound (TMJ-sound, percussion)
out the need of real teeth or expensive plastic ones. O High quality images (no cost for printing)
The computer may help the student by guiding him/ O Immediate results
her in clinical procedures. The building of fast net- O Time measuring (How much time does a student
work connections will enhance the possibility of pro- devote to different questions? Can he better use his
viding the learner with high quality images and up- time?)
dated information. O In case of a wrong answer, the student can be given
a second chance (is the student on the correct track)
Examination (48).
As in CAL, the computer-mediated test could put the The exam can be given any time, place, or in privacy
student in the role of a diagnosing professional. The without the faculty member present.
computer presents a short case to the student and asks
him to collect essential facts (history, status, x-rays
Conclusion
etc). Based on the information available, the student
is asked to provide a diagnosis, suggest a treatment Computers are common in dental clinics and pro-
and provide a prognosis. The computer simulates an cessor-based equipment is used in dental therapy. The
outcome depending on the student’s treatment sug- use of computers cannot be optimised until education
gestions. The student can then ask for additional facts, in computer skills is included in the undergraduate
if necessary, and then try to request the appropriate courses. Computer education should therefore be
treatment alternative. (See Fig. 1). mandatory in the dental curriculum. Also, it is im-
The concept of virtual patients in Computer As- portant that teachers provide role models for stu-
sisted Virtual Examination (CAVE) is not new but was dents. In addition, the resource persons should be
mentioned in 1990 as a potential possibility (48). The well acquainted with the use of high-quality educa-
advantages of CAVE would be: tional programs based on CAL. Some authors suggest
O Moving pictures (showing mobility, lower jaw that students will even choose dental schools depend-
movement, swallowing pattern) ing on the extent to which access to CAL is provided.

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TABLE 1. Summarising advantages and disadvantages of CAL from and environmental health and medicine. Occup Med 1998:
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Advantages Disadvantages are we going? In: Computer Assisted Learning Material.
Eastman Dental Institute for Oral Health Care, 2000. Avail-
O The student can choose his O Starting costs are high.
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O The program can be repeated Medical Computing 1996: 13: 4330–4334.
as often as the user wishes. 13. Dugas M, Batschkus M, Lyon H. Mr Lewis On the Web-
O The computer is not judg- how to convert learning resources for Intranet technology.
mental. The student can learn Medical Education 1999: 33: 42–46.
from his mistakes without em- 14. Plasschaert AJ, Cailleteau JG, Verdonschot EH. The effect
barrassment. of a multimedia interactive tutorial on learning endodontic
O Saves time for the teacher (in problem solving. Eur J Dent Educ 1997: 1: 66–69.
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O The students are more acti- Learning at the computer: Evaluation of an intelligent tu-
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O Weak students are favoured.
16. Mendel RW, Scheetz JP. The effect of teaching method on
(15, 34)
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552.
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