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Learning with web-based interactive objects: An investigation into student

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Contents lists available at ScienceDirect

Computers & Education

journal homepage: www.elsevier.com/locate/compedu

Learning with web-based interactive objects: An investigation into student

perceptions of effectiveness
Florin D. Salajan *, Susanne Perschbacher, Mindy Cash, Reena Talwar, Wafa El-Badrawy, Greg J. Mount
University of Toronto, Faculty of Dentistry, 458-124 Edward Street, Toronto ON, Canada M5G 1G6

a r t i c l e i n f o a b s t r a c t

Article history: In its efforts to continue the modernization of its curriculum, the Faculty of Dentistry at the University of
Received 16 August 2008 Toronto has developed a series of web-based interactive learning applications. This article presents the
Received in revised form 31 March 2009 production cycle of these new interactive learning objects and the preliminary study conducted to mea-
Accepted 5 April 2009
sure the students’ perception of the objects’ effectiveness for learning. Three applications are described in
detail in this article, namely: Panoramic Radiography: Principles and Interpretation, Gross Human Anatomy
3D Atlas and Restorative Dentistry: Virtual and Interactive Cavity Preparation. Each of these applications
Keywords:
introduces unique elements of interactivity with the learning content, specifically designed to address
Instructional design
Interactive objects
hard-to-grasp concepts in their respective dental disciplines. The results of a student survey conducted
Web-based applications post-deployment suggest that the visual and interactive features embedded in the three applications
2D and 3D animations have the potential to induce positive outcomes in mediating the students’ conceptualization of difficult
Learning effectiveness theoretical notions.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction

With the advent of web-based digital interactive technologies and 3D graphics, teaching and learning methodologies have changed to a
certain degree in order to accommodate these new arrivals in the instructional setting. On the one hand, as a testament to the entertain-
ment value of interactive technologies, video and computer gaming has generated a multiple billion dollar industry over the past three
decades (Strube, Schade, Schmidt, & Bruxmann, 2007). On the other hand, while there is general agreement that interactive technologies
have benefited educational objectives, the overall picture is less clear on how effective they have proven in stimulating the learners’ knowl-
edge formation and retention. The uncertainty about learning effectiveness stems, in part, from the still relative novel application of inter-
active technologies in education, particularly through web delivery. What is certain about web-based interactive technologies is that they
do show a great potential for improving teaching and learning.
In the medical or health sciences, including dentistry, the combination of interactive technologies and 3D graphics has resulted in cut-
ting-edge learning objects or programs in recent times. A series of studies describing the development and implementation of interactive
3D models illustrates the potential advantages of using interactive technologies for instruction. For a useful survey of some of the three-
dimensional web-based interactive applications for medical education developed between 1995 and 2005, Nigel’s (2007) informative
paper represents a good, but not necessarily exhaustive, starting point to get an assessment of how these technologies have been incor-
porated into medical teaching.
One of the more prominent applications in this field was the Internet Atlas of Human Gross Anatomy, developed at Johannes Gutenberg
University in Mainz, Germany, and based on high resolution images from the United States National Library of Medicine’s Visible Human
Project (Jastrow & Vollrath, 2002, p. 402). Jastrow and Vollrath’s assessment of the program indicated that it constituted an ‘‘excellent basis
for anatomical and radiologic understanding for the training of the medical students, doctors and staff” (p. 408). Another, more recent
study, partly based on components of the Visible Human Project, sought to evaluate a three-dimensional model for the teaching of the adult
brachial plexus at the Imperial College London (Brenton, Hernandez, Bello, Strutton, Purkayastha, & Firth, et al., 2007). While, at the time of
the study’s publication, the model was still being evaluated, the authors were working under the assumption that the introduction of the
3D model ‘‘into existing teaching will improve students’ knowledge and retention of the brachial plexus” (p. 49). Through that study, Bren-
ton et al. attempted to respond to the concern we presented above related to the lack of tangible evidence that the interactive technologies

* Corresponding author. Tel.: +1 416 979 4909x4664; fax: +1 416 979 4936.
E-mail address: fl[email protected] (F.D. Salajan).

0360-1315/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compedu.2009.04.006
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 633

do enhance learning. They acknowledged the fact that ‘‘evaluation is often informal and rarely examines the longitudinal retention of
knowledge by students” (p. 40).
In dentistry, some evidence suggests that there is increased interest in dental schools for web-based interactive models of instruction
using three-dimensional features. There is recognition that 3D modeling and animation constitute a ‘‘logical and feasible evolution in cur-
ricular enhancement,” via which students can expand their ‘‘conceptual understanding” of ‘‘cavity design, discrimination learning, and pro-
cedural critique in a self-directed, self-paced learning environment” (Gianquinto, Mecadon, Boberick, Salkin, Gross, & Esposito, 2005, p. 98).
However, successful examples of these types of applications are still relatively rare in the dental education literature. One notable example
is the Web-based 3D Online Crown Preparation Course developed at the Temple University School of Dentistry, the objective of which was to
provide the knowledge foundation the students would need during their preclinical skill development for full crown preparations (Spallek,
Kaiser, Boberick, Boston, & Schleyer, 2000, p. 1). The authors of the course explained that the school’s strategic computing plan required
that any new application had to be ‘‘tightly integrated” into the ‘‘existing intranet,” and, thus, ‘‘only a Web-based application could be used
for such a teaching tool” (p. 2). A recent study evaluated a web-based application including interactive 2D and 3D elements designed for the
anatomical interpretation of cone beam computed tomography (Al-Rawi, Jacobs, Hassan, Sanderink, & Scarfe, 2007). The results of the
study indicated that the instructional effectiveness of the application in conveying the concepts taught was at least as high as that of tra-
ditional instructional materials. However, the study concluded that continued evaluation was needed to determine how the application can
further enhance the students’ learning processes (p. 464). A similar approach, with similar results, was undertaken in another study de-
signed to compare the effectiveness of a web-based interactive multimedia package with standard lectures in orthodontics. Namely, the
results revealed that the interactive program proved to be at least as effective as the traditional method of delivery. Nevertheless, further
research was needed to investigate the underlying cognitive processes induced by computer-assisted learning in dental education (Aly,
Ellen, & Willems, 2004, p. 46).
This article contributes to and expands this framework of research on and development of web-based interactive instruction with a ser-
ies of newly created learning modules at the Faculty of Dentistry, University of Toronto. It presents and describes the production cycle of
three interactive applications built during a courseware development project in the summer of 2007. Each application was designed to
meet learning objectives in three different dental disciplines of the Doctor of Dental Surgery (DDS) program:

 The Panoramic Radiography: Principles and Interpretation, for third- and fourth-year students in Oral Radiology courses.
 The Gross Anatomy 3D Atlas of the head and neck, for students in the first-year course in Gross Anatomy.
 The Interactive Cavity Preparations, for students in the first-year course in Restorative Dentistry.

The three applications have been in use since the fall semester of 2007. Research data collected via a student questionnaire distributed
online during the spring semester of 2008 has provided us with a set of results that indicate the potential of the web-based interactive
applications to effect positive outcomes in the students’ learning of theoretical content. The results of this preliminary study are presented
at length in the later part of this article.
The article is divided as follows: Section 1 introduces the current preliminary study; Section 2 provides a brief discussion of the theo-
retical underpinnings of interactivity; Section 3 contains a description of the project structure, design methodology and production; Sec-
tion 4 presents each application with its functional and instructional features; Section 5 describes at length the results of the research
conducted to measure the perceived effectiveness of the applications; Section 6 summarizes the article and suggests directions for future
research on interactive applications.

2. Interactivity in context

Dental education’s end purpose is to produce highly specialized professionals who can interact with their patients expertly and effi-
ciently. However, the means through which the students learn the skills they need as practitioners vary with the dental curriculum through
which they are trained. Web-based, interactive course materials are increasingly a part of that curriculum. At the University of Toronto,
dental students have only in recent years begun to use web-based interactive programs (Salajan & Mount, 2008; Cohen, Walker, Tenen-
baum, & Spero, 2003). In order to provide a more thorough understanding of the specific application of interactive objects at the Faculty
of Dentistry, a brief overview of the principles of interactivity employed in their development and assessment is necessary.
Interactivity has long been recognized as a critical feature in learning transactions and as a key factor in developing instructional mate-
rials. In describing the concept, Sims (1997) quotes Barker (1994) as stating that interactivity in education is ‘‘a necessary and fundamental
mechanism for knowledge acquisition and the development of both cognitive and physical skills” (p. 157). Sims goes on further to decon-
struct the notion of interactivity to its operational substratum in learning dynamics, interaction, which, in his interpretation, is ‘‘intrinsic to
successful, effective instructional practice as well as individual discovery.” (p. 158). Apart from interaction, he further contends that elic-
iting user engagement with the interface constitutes the driving factor in developing educational media.
Several frameworks of interactivity have been advanced for web-based learning. Sims (1997) identified eleven levels of interactivity that
can be taken into consideration when building interactive learning systems: object interactivity, linear interactivity, hierarchical interactivity,
simulation interactivity, virtual interactivity (or virtual reality), to name just a few (p. 162). Following the work of Borsook and Higginbotham-
Wheat (1991) on interactivity in computer-based instruction, Chou (2003) refers to their guidelines in developing interactive web-based
learning systems which include elements such as immediacy of response, non-sequential/non-linear access to information, adaptability,
feedback, a sufficient number of user options, bi-directional communication channels, and appropriate grain-size or interruptability (p. 267).
When it comes to the fundamentals of interaction between humans and computers in a learning environment, Evans and Gibbons
(2007) identify two types of interactivity: student-initiated interactivity and computer-initiated interactivity (p. 1148). These two types
of interactivity form the basis of Evans and Sabry’s (2003) ‘‘three-stage model of computer-initiated interaction” consisting of three
sequential actions:

 Computer initiation: the computer presents a task or a series of options to the learner, in the form of a question or button (e.g., click here
to begin);
634 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643

 Learner response: the learner selects an action in response to the options presented by the computer in the initiation stage;
 Computer feedback: the computer presents the learner a new screen containing an assessment of the learner’s response (p. 90).

This iterative process is ubiquitous in web-based interactive learning systems and the applications we are presenting in this article ob-
serve this interaction model. The elements of initiation, response and feedback were taken into consideration both in the development of
the applications and in the questionnaires investigating student perceptions regarding the applications’ effectiveness for learning.
Sections 4 and 5 describe in detail the process through which these interactive features were developed and assessed. The following
section provides the background story and the circumstances in which the courseware development project was carried out at the Faculty
of Dentistry.

3. The second project

The courseware development project presented in this article was undertaken at the University of Toronto’s Faculty of Dentistry in the
summer of 2007 as a logical and natural follow-up of the previous summer’s courseware pilot-project (Salajan & Mount, 2008). The adop-
tion of the BlackboardÒ learning management system by the parent university in January 2006 prompted the Faculty’s drive to incorporate
digital course material in its curriculum. Consequently, the summer 2006 pilot-project resulted in a series of ten courses with learning
materials delivered through Blackboard, which represented a novel approach for course management at the Faculty. However, apart from
digitizing and storing course lecture material in Blackboard, the development team identified the potential for interactive media elements
that could be delivered via the same route. Thus, the development team prototyped two interactive programs, the Oral Pathology Virtual
Microscope and the Virtual Cavity Preparations, to be used in conjunction with the corresponding disciplinary courses (p. 539).
The pilot-project had provided the foundation for a collaborative environment in which faculty members, students in the DDS program
and educational technologists could work together to infuse the dental curriculum with technology-enhanced teaching methods. It had
also revealed the need for highly-interactive and visually-captivating applications to be developed in dentistry, a domain of study that
is intrinsically dependent upon the visual field to convey cognitive functions.
Building on the developments of the pilot-project, a more comprehensive courseware development project was rolled out in the sum-
mer of 2007. The objective of this second courseware development project was the creation of six web-based 2D and 3D interactive multi-
media applications, one each for Oral Radiology, Oral and Maxillofacial Surgery, Restorative Dentistry, Prosthodontics, Biomaterials, and
Preventive Dentistry. In turn, each of these applications was meant to meet a specific learning objective in its respective discipline (see
Table 1).
Similar to the process followed during the pilot-project, a courseware development team was put together in order to create these appli-
cations. The team consisted of the faculty members teaching the six courses, two dental students, two graphic designers, and the academic
technology specialist. The six faculty members had been selected for the project following a call for participation released to the entire
teaching body of the Faculty.
Once the learning and project objectives were outlined, the project workflow comprised weekly meetings between the courseware
developers and each of the six participating faculty members. At the meetings, each faculty member provided the specific discipline exper-
tise in developing the content for the application. The DDS students had a significant contribution in influencing the direction in which the
applications were developed. Their perspective was instrumental in the design of an interface that the students would consider relevant
and appropriate for knowledge acquisition. Finally, the team of developers designed and integrated all the multimedia components into the
user interface. Three of the applications thus created are the focus of this article, as well as the preliminary study conducted to assess their
perceived effectiveness as learning tools. The following section provides a description of the features built into the applications, along with
a brief overview of the technologies employed in their production.

4. New applications revealed

4.1. Technical production process

Each of the interactive applications developed during the project were meant to function either as stand-alone units or in tandem with
other course materials in the Blackboard learning management system. They were hosted on a reliable and secure internal web-server at
the Faculty, allowing direct access both internally and externally. Hyperlinks pointing to the applications’ individual addresses on the web-
server were then placed on the Blackboard course pages to which the applications were relevant. The production process of the three appli-
cations consisted of the following tasks:

 The 3D graphics used in the three applications were created, manipulated, rendered and optimized through the software packages Auto-
desk Maya 8.5 and Autodesk 3DS Max 9, respectively.

Table 1
Disciplines and their learning needs.

Discipline Learning needs

Oral Radiology Principles of Panoramic Radiography techniques and interpretation
Oral and Maxillofacial Surgery Head and neck gross anatomy, including cranial muscles and nerve pathways
Restorative Dentistry Techniques of cavity preparations
Prosthodontics Designing removable partial dentures
Biomaterials Video demonstration of biomaterial compound amalgamation
Preventive Dentistry Conducting a proper oral hygiene session
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 635

 The relevant 2D static images embedded in the applications were either newly obtained through digital photography, were optimized
from pre-existing digital images or, in several instances, were converted from flat copies to digital format through scanning.
 The user interface including the layout and navigational components for the three applications was designed and created using Adobe
Photoshop and Flash CS3;
 The animation of 2D and 3D components and of the self-assessment testing units was programmed in Actionscript 2.0 (AS2).
 Each application resulted in a number of Shockwave Files (SWF) containing its particular topical sections. A main SWF file serving as the
access point into each application and its adjacent sections was published.
 Finally, each main SWF file was embedded into an HTML file with pre-determined browser window dimensions for optimized screen
viewing. The HTML file thus created is launched from a hyperlink as mentioned above.

The following sub-sections provide a thorough description of the learning purposes and functionality of the three individual
applications.

4.2. Panoramic Radiography: Principles and Interpretation

The Panoramic Radiography: Principles and Interpretation application was developed to teach the concept of capturing and interpreting
panoramic radiographs in dentistry. Panoramic Radiography is hard to visualize with the 2D learning materials traditionally used in the
third year oral radiology course (Perschbacher, Cash, & Dayal, 2008). The panoramic radiograph depicts the three-dimensional anatomy
of both jaws, the dentition and many surrounding structures on a single two-dimensional image. Challenges in teaching Panoramic Radi-
ography arise due to the complex theory and physics of the technology. The principles of properly positioning a patient for image acqui-
sition are also difficult to demonstrate. Additionally, students struggle to understand the multiple overlapping cranial and facial structures
(e.g., bones, soft tissues and airways) as they present on the panoramic image and to differentiate them from abnormal entities.
To better convey the concepts involved in Panoramic Radiography and to overcome the learning challenges outlined above, the Pano-
ramic Radiography module includes three main chapters: Theory and Image Acquisition, Panoramic Anatomy, and Interpretation of Pano-
ramic Radiographs. The first chapter, Theory and Image Acquisition covers the basic concepts of image acquisition and is divided into five
sections:

 Introduction to tomography – introduces the learner to the physical principles of tomography, demonstrated through a series of 2D
graphics and a 3D animated video.
 Dental panoramic tomography – explains the difference between a tomographic image taken by an X-ray source in a flat focal plane and
one taken in a curved plane, as is required to image the jaws, with 2D graphics and a 3D animated video.
 Steps to taking a panoramic radiograph – presents a list of procedural steps to ensure the appropriate preparation of the patient for the
radiograph.
 Errors in patient positioning – this section uses a series of interactive screens to simulate errors in the positioning of a patient’s maxilla
and mandible in the focal trough of a panoramic radiograph machine. The learner can choose between the correct position and six com-
mon wrong positions that would result in blurred or distorted radiographic images. Fig. 1 shows the correct positioning of the patient’s
head. Once the user chooses a position, multiple 2D images depict the patient’s position with respect to positional guides and a rotating
3D graphic shows the resulting displacement of the mandible from the ideal position. When the learner selects to ‘‘expose” the radio-
graph he/she is taken to the next screen which will allow her/him to see the resulting black and white radiograph as if the negative film
‘‘unrolls” in front of her/his eyes. A 2D animation next to the unrolling film provides the schematic depiction of the panoramic device’s
rotation, from an overhead vantage point. In addition, a description of the resulting image distortions is provided.
 Explore your understanding – provides the students with nine review questions on the concepts introduced in the chapter. Each ques-
tion relates to a certain feature of a radiograph. Feedback is provided through a simple answer button and in some cases tips are also
provided to guide the student through the analysis.

Fig. 1. Panoramic Radiography Module showing errors in patient positioning.

636 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643

The second chapter in the application, Panoramic Anatomy, illustrates the hard and soft tissues, the air spaces and the ‘‘ghost shadows”
that appear on a panoramic radiograph due to the juxtaposition of a number of cranial and facial structures into a two-dimensional plane.
An image is presented for each type of structure, which is then marked with intermittently fading overlays that correspond to the specific
part of the anatomy described. A self-assessment component contains eleven radiographs, each serving two functions:

 To review the many structures of the head marked with the intermittently fading overlays. In this component, the learner selects a struc-
ture from a drop-down menu, which is then highlighted as described above.
 For many structures, the student can select to see a photograph of a skull on which the anatomic part is outlined. This is intended to
reinforce correlation of the gross anatomic appearance with the radiographic presentation.
 To challenge one’s knowledge of the structures learned. Each radiograph displayed for the first time presents a flashing contour on the
image. The learner has three chances to select the correct name of the structure represented by the contour, by selecting an option from a
drop-down list of terms. If, after three tries, the learner does not get the right answer, this will be displayed and the student moves on to
the next structure. Each radiograph tests multiple structures.

Finally, the last chapter, Interpretation of Panoramic Radiographs, allows the learner to engage in interactive diagnosis and self-assess-
ment, giving the learner the opportunity to identify variations and pathologies that may be seen on panoramic radiographs. Each of the
twenty radiographs included in the section is accompanied by a question that the student has to answer. Depending on the question,
two or three tip buttons, followed by an answer button, are provided in a conditionally sequenced order (e.g., Tip 2 can only be displayed
after viewing Tip 1; the answer button is displayed only after the tips were exhausted). This type of feedback is intended to stimulate
reflection on and exploration of the structures displayed on the screen before deciding on a diagnosis.

4.3. Gross Human Anatomy 3D Atlas

The application developed for the first-year dental students in the gross anatomy course uses a 3D model of a cranium, overlaid with
muscle tissue and a generic male facial representation. As was the case with the previous application described, the atlas was developed to
address the lack of three-dimensional multimedia programs specifically focused on the anatomy of the head and neck, and especially the
three-dimensional visualization of the cranial nerves. The atlas is divided into five sections, each covering a certain aspect of the head and
neck gross anatomy:

 Skull and Sutures – introduces the fundamental structures of the neuro- and viscero–cranium, as well as the identification of bony
sutures.
 Muscles of Mastication – outlines the four major muscles of mastication and their anatomical relationship to one another, as well as to
the supporting bones.
 Muscles of Facial Expression – outlines all of the muscles of facial expression and their anatomical relationship to one another, as well as
to the supporting bones.
 Cranial Nerves – identifies the origin and function of the twelve cranial nerves.
 Head and Neck Ganglia – identifies the four major ganglia of the head and neck region. In addition, several case-studies have been
included to test the learners’ knowledge.

Fig. 2 illustrates the layout and design of the 3D atlas. The tabbed interface allows the learner to easily navigate from one section to
another. The layout of the interface is consistent across the thematic sections, essentially divided into three panels. For each section,
the leftmost panel lists the various anatomical components of the section’s theme. The middle panel, the principal interactive element
of the application, contains the three-dimensional visualization of the human head. Finally, the panel on the right-hand side of the screen
provides a description of the individual anatomical component selected from the list on the left-hand side of the screen.

Fig. 2. The Gross Human Anatomy 3D atlas of the head and neck, showing the section on the muscles of facial expression.
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 637

The atlas is built in an intuitive and straightforward manner. Once within a section of the atlas, the user can select a choice from the list
on the left. The middle panel then highlights that component on the cranium. Two controls are provided at the bottom of the middle panel,
serving two functions:

 Rotate – rotates the skull 360° in the horizontal plane, with an intermediate ‘‘inferior” position which rotates the cranium upwards, thus
showing a view of the internal structures of the cranium.
 Dissect – fades all the soft tissue structures of the head, except for the selected anatomical component and the osseous structure itself.

These two functions operate independently from each other and can be manipulated to expose as much of the structure as desired (e.g.,
rotate halfway and full dissect/fadeout, etc.). A number of case-studies, accompanied by a mock ‘‘fill in the blanks” question, provide the
learner with a self-assessment tool. An answer button provides the missing parts of the question once the learner is ready for feedback.

4.4. Restorative Dentistry: Virtual and Interactive Cavity Preparation

The Virtual and Interactive Cavity Preparation applications were developed for the first-year students in the Restorative Dentistry
course. While the two applications could be used as stand-alone programs in the curriculum, they are better viewed as two modules com-
plementing each other. The first module, Virtual Cavity Preparation, uses 3D graphics to demonstrate the design and components of dif-
ferent cavity preparations (see Fig. 3). The second module allows simulated drilling sessions on various teeth and, thus, was named
Interactive Cavity Preparation (see Fig. 4).
Virtual Cavity Preparation allows the learner to visualize seven cavity preparations by positioning side by side two images of prepara-
tion classes (in the example in Fig. 3, a class 2 is shown). The interface is similar to the one designed for the 3D atlas (see Section 4.3.). Three
panels arranged from the left to the right of the screen contain, in this order: a menu list of class preparations, a visual field where the
cavity preparations are displayed in 3D graphics and a right panel containing a legend for the color-coding used in the cavity preparations,
along with sets of additional 2D annotated images of the preparation class displayed. As in the case of the 3D atlas, the middle panel is the
main feature of the application. It contains a side-by-side comparison of a gypsum cast of a tooth and its 3D graphical representation. The
gypsum cast is the model the students normally use in the course to learn the principles of cavity preparation. The 3D model features trans-
parency and color-coding so that the learner can have a better visualization of the preparation’s degrees of depth and of the tooth’s internal
structure. The two objects rotate in tandem a full 360° on a horizontal plane.
Interactive Cavity Preparation (Fig. 4) provides the learner with a simulated ‘‘drilling session.” The application contains two sections.
The first section shows animations of the different types of burs used to prepare a cavity and the shape of the cut they leave in the dental
tissue. The second section contains the drilling simulation for three classes of preparation (1, 2, and 5) on a total of 15 images of model
teeth. Each session is a self-test of the accuracy with which the learner can trace the shape of the ideal cavity preparation on a selected
preparation class/tooth combination. A button prompts the learner to begin the session, following which, the learner proceeds to trace
the shape and contour of the preparation to the best of her/his knowledge. Once the learner concludes that the session is over, s/he clicks
the ‘‘Done” button. Upon this action, the application provides the learner with feedback which lets her/him know how long the session
lasted. This feedback also suggests the ideal length of the session and the optimal contour of the preparation shown as a dotted line on
the model tooth. Both modules serve as good practice tools for students to visualize and understand the techniques of cavity preparations
which can help them in the clinical setting.

4.5. Incorporation into the curriculum

Upon the completion of their design, the three applications were included in the courses as supplemental tools that addressed specific
aspects of those courses. They could not and were not meant to supplant the existing course materials or to completely replace the tradi-
tional teaching and learning methods. Instead, as can be surmised form the descriptions above, they focused on specific topics that are part

Fig. 3. Virtual Cavity Preparation, showing the design of cavity preparations on different teeth.
638 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643

Fig. 4. Interactive Cavity Preparation, showing the outcome of a ‘‘drilling” session.

of the foundational knowledge of the particular courses in which they were deployed. Formal academic testing, either based solely on the
content included in the applications or in relation to their use with other course materials, was not envisioned nor considered necessary at
that time.
The individual interactive applications were each used to a varying extent in their particular courses, depending on the subjects and
topics targeted. None of the applications, however, were comprehensive enough to cover all aspects of a one-year dental course. As such,
they were intended to enhance learning by facilitating interaction with a visual medium built to illustrate abstract or complex theoretical
notions.

5. Assessing the perceived effectiveness of the applications

As a first step towards the assessment of the interactive objects developed at the Faculty of Dentistry, we devised a preliminary study to
gather information on the perceived effectiveness of the applications. This study represents an incipient stage in the development of a more
comprehensive program of research for the evaluation of the current and future development of interactive learning objects at the Faculty.
The rest of this section provides a detailed description and analysis of the study’s results.

5.1. Students’ educational profile

The dental students surveyed in the study were part of the first-, third- and fourth-year cohorts in the DDS program. Henceforth in this
article, we will refer to them as DDS-I, DDS-III and DDS-IV, respectively. Because demographic data was not collected through the ques-
tionnaires, we constructed a profile of the students involved in the preliminary study based on data drawn from aggregate information
available for each cohort from admission files. Hence, the profile provided here is not an exact description of the students in the response
samples, but rather of the entire targeted samples consisting of the three cohorts of dental students.
Each year, the Faculty of Dentistry admits approximately 65 students in the first-year DDS program with a roughly equal distribution
between male and female students. More than 90% of the students registered each year come from the province of Ontario, with a small
percentage coming from other provinces. One of the requirements for admission into the DDS program is at least three years of university-
level education. While the percentage of students with three years of university-level education varies each year, those who have
completed at least four years usually constitute the bulk of admitted students and consistently exceed 50% of the students admitted.
The percentage of students with graduate degrees (Master or Doctoral level) can fluctuate anywhere from less than 5% to more than
30% in some years. Table 2 provides a detailed breakdown of the three cohorts’ pre-dental school educational background and achieve-
ments at the time of each particular cohort’s admission into the DDS program.
Students seeking admission into the DDS program at the University of Toronto must also satisfy the completion of five full-year univer-
sity-level courses in the following subject areas: one course in general biochemistry, one course in general mammalian (human or animal)
physiology, two courses in life sciences (e.g., anatomy, biology, botany, etc.) and one course in humanities or social sciences.
In addition to the regular first-year cohorts, each spring the Faculty admits about 25 to 30 international students with dental degrees
from non-accredited universities abroad into the International Dentist Advanced Placement Program for Foreign-Trained Dentists (IDAPP).
Upon their successful completion of this five-month program, the IDAPP students join the third-year cohort in the fall semester.

5.2. Survey instrument

In order to gauge the impact that the three applications have had on the learning outcomes of the students who used them, we deployed
an electronic questionnaire in Blackboard, linked from the courses for which the applications were developed. The questionnaire contained
eight closed-answer questions and one open-answer question divided in the following categories:
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 639

Table 2
DDS students’ educational background.

DDS-I DDS-III DDS-IV

N % N % N %
Total registered students 64 100 64 100 65 100
Male 31 48.4 36 56.3 26 40
Female 33 51.6 28 43.8 39 60
Distribution by province
Ontario 60 93.8 59 92.2 59 90.8
Other 4 6.3 5 7.8 4 6.2
Level of university education
Three years 9 14.1 27 42.2 16 24.6
Four (or more) years 35 54.7 35 54.7 42 64.6
Master’s degree 18 28.1 2 3.1 5 7.7
Ph.D. degree 2 3.1 0 0 0 0
Mean grade point average (4.0 scale) 3.8 3.84 3.81
Mean DAT scores (0–30 range)*
Academic average (AA) 21 20 20
Perceptual ability (PAT) 19 18 19

Source: Office of Student Services (OSS) at the Faculty of Dentistry, University of Toronto. The data for each cohort was collected by OSS at the time that each cohort was
admitted into the DDS program (i.e., in 2007 for DDS-I, 2005 for DDS-III and 2004 for DDS-IV, respectively).
*
DAT stands for the Dental Aptitudes Test, administered by the Canadian Dental Association. It is a requirement for admission in Canadian dental schools. For more
information see <http://www.cda-adc.ca/en/dental_profession/dat/information/default.asp>.

 Three multiple-choice questions asking the students the frequency, purpose and location of their use of the applications (see Section 5.4.
for a description and analysis of the questions and the corresponding responses).
 Five opinion scale or Likert questions asking students their perception on the learning expectations and outcomes in relation to the func-
tionality afforded by the graphical components included in the applications.
 An open text field for optional essay responses.

Although the choice and structure of the questions were uniform across the three applications assessed, the questionnaire template was
customized for each of the three applications by simply replacing the name of the application wherever necessary within a question. The
questionnaire for the Panoramic Radiography Module was distributed to the combined cohorts of DDS-III and DDS-IV students who used
the application, while the questionnaires for the Gross Anatomy 3D Atlas and for the Interactive Cavity Preparation were distributed to the
DDS-I students.
The five opinion scale questions were designed to investigate the perceived level of interactivity that the students experienced in using
the applications. Table 3 shows the formulation of the questions, the order in which they were inserted in the questionnaires and the re-
sponse scales attached to each question.
The answers to these questions were considered central to the task of assessing the overall perceived effectiveness for learning of the
interactive components that were built into the applications (see Section 5.4.). The analysis and results of this assessment are presented in
the following sections.

5.3. Data collection and response rates

The questionnaires were deployed during the spring semester of 2008, immediately after the final exams in the three courses surveyed.
Since each course had set its final exam at different dates during the semester, the response rates varied according to the length of time left
between the final exam and the end of the semester. In total, the data collection extended over approximately 22 weeks. Table 4 presents
the breakdown of the response rates per each application.
The number of potential responses corresponds to the number of students contained in the courses for which the applications were
developed. Although the number of received responses for each application was higher than that shown in the table, incomplete responses
were eliminated for the purposes of this analysis. Thus, only the numbers of complete responses for each application were retained for
analysis and are shown in the column for received responses.

Table 3
Opinion scale questions with range of possible answers.

Question Response scale

To what extent do you think that the (application) was useful in helping you reinforce and/or expand your knowledge of the Not useful at all (1) ? Extremely useful
course material covered in class? (5)
How would you rate the (application)’s user interface? Very difficult to use (1) ? Very easy to
use (5)
How would you rate the (application)’s graphic depictions of the concepts you learned in class? Very inaccurate (1) ? Very accurate (5)
What level of interactivity would you attribute to the content of the (application)? No interactivity (1) ? High interactivity
(5)
Did the choice of concepts and topics included in the (application) meet your learning expectations? Not at all (1) ? Absolutely (5)
640 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643

Table 4
Response rates per application.

Application Potential responses Received responses Response rate (%)

Panoramic Radiography 164 55 33.5
Gross Anatomy 3D Atlas 64 44 68.8
Interactive Cavity Preparation 64 27 42.2

5.4. Findings

The first set of three questions requesting information about the students’ frequency, purpose and location of use yielded mixed pat-
terns of usage across the three applications (see Table 5). It is interesting to note, for example, that among the DDS-I cohort of students,
the Gross Anatomy 3D Atlas was used three or more than three times throughout the semester by a larger number of students than the
Interactive Cavity Preparation in that same frequency category. On the other hand, there were more DDS-I students who used the Inter-
active Cavity Preparation only one time as opposed to the Gross Anatomy 3D Atlas. As far as the Panoramic Radiography Module is con-
cerned, the frequency of usage was somewhat balanced between DDS-III and DDS-IV students who used the application three or more than
three times and those who used it only one time. The question on the purpose of use allowed students to select multiple answers from the
five possible options.
The five opinion scale questions provided five unique data points of analysis. The textual responses received through the questions were
converted to numerical values on a scale from 1 to 5 (with 1 being the lowest and 5 being the highest value, respectively), which could then
be checked for correlations. For each of the three applications, a data set was generated containing the five data points corresponding to the
five opinion scale questions in the three respective instances of the questionnaire. The data points were labeled as variables I1 to I5 (with I
standing for interactivity), corresponding to the order of the five questions in the questionnaire (see Section 5.2.). For the purpose of this
investigation, a bivariate analysis using Spearman’s test for non-parametric correlation was chosen in order to reveal the strength of rela-
tionships among the data points. Tables 6–8 present the correlation coefficients for the variables in the three data sets and the statistical
significance of the resulting correlations.

5.5. Discussion

The data presented in Tables 6–8 indicate slight contrasts among the three applications regarding the connection between interactivity
and learning effectiveness. At the general level, the Panoramic Radiography Module scored higher median values on most variables com-
pared to either the Gross Anatomy 3D Atlas or the Interactive Cavity Preparation. This is especially the case for the variables that are most
relevant in relation to the influence of interactivity on learning effectiveness. Thus, variables I1, I4 and I5, which correspond to questions 1,
4 and 5, respectively, are rated half-to one value point higher in Panoramic Radiography (median of 4.00 per variable) than in the Gross
Anatomy 3D Atlas (medians of 3.00 for two variables and 3.50 for one variable) or the Interactive Cavity Preparation (median of 3.00
per variable).
While the mean and median values recorded reveal an overall positive assessment of the learning objects by the users, it is the corre-
lations tables that establish the strength of the connection between interactivity and learning outcomes. The main indicators of the effect of
interactivity levels on learning are the correlations that emerge when variable I1 and I5 are paired individually with variable I4. Recalling
the list of five questions in Section 5.1, questions 1 and 5 (corresponding to variables I1 and I5) were designed to elicit responses on the
extent to which the applications were useful in supporting the learning materials covered in the courses, as well as on how well the stu-
dents’ learning expectations were met by the applications. In this respect, the interactivity levels embedded in the Panoramic Radiography
Module render this application as the most effective for learning of all three. Variable I4’s correlations with both I1 and I5 are not only

Table 5
Usage frequency, purpose and location for the interactive applications.

Usage patterns Panoramic Radiography (%) (n = 55) Gross Anatomy 3D Atlas (%) (n = 44) Interactive Cavity Preparation (%) (n = 27)
Frequency of use
One time 34.54 (19) 4.54 (2) 37.04 (10)
Two times 16.36 (9) 25 (11) 22.22 (6)
Three times 23.64 (13) 38.64 (17) 11.11 (3)
More than three times 23.64 (13) 31.82 (14) 22.22 (6)
Unanswered 1.82 (1) – 7.41 (2)
Purpose of use
Study before exam 60 (33) 75 (33) 44.44 (12)
Study before class 12.73 (7) – 7.41 (2)
Lecture material supplement 36.36 (20) 25 (11) 29.63 (8)
Review after class 14.55 (8) 9.09 (4) 25.93 (7)
Reference tool throughout semester 38.18 (21) 31.82 (14) 18.52 (5)
Unanswered 3.64 (2) – 3.70 (1)
Location of use
Primarily at school 43.63 (24) – 7.41 (2)
Primarily at home 32.73 (18) 95.45 (42) 88.89 (24)
Equally frequently at home/school 23.64 (13) 4.55 (2) –
Other locations – – –
Unanswered – – 3.70 (1)
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 641

Table 6
Correlations for the Panoramic Radiography Module.

Variables Values Correlations

a
Mean Median SD I1 I2 I3 I4 I5
I1 3.89 4.00 .936 – .192 .466** .494** .652**
I2 4.01 4.00 .652 .192 – .536** .298* .393**
I3 4.05 4.00 .730 .466** .536** – .572** .577**
I4 3.74 4.00 .725 .494** .298* .572** – .687**
I5 3.94 4.00 .704 .652** .393** .577** .687** –
a
SD = Standard deviation.
*
Correlation is significant at the 0.05 level (2-tailed).
**
Correlation is significant at the 0.01 level (2-tailed).

Table 7
Correlations for the Gross Anatomy 3D Atlas.

Variables Values Correlations

a
Mean Median SD I1 I2 I3 I4 I5
I1 2.88 3.00 .579 – .239 .170 .430** .427**
I2 4.11 4.00 .654 .239 – .321* .014 .036
I3 3.84 4.00 .713 .170 .321** – .320* .124
I4 3.43 3.50 .695 .430** .014 .320* – .346*
I5 3.06 3.00 .586 .427** .036 .124 .346* –
a
SD = Standard deviation.
*
Correlation is significant at the 0.05 level (2-tailed).
**
Correlation is significant at the 0.01 level (2-tailed).

Table 8
Correlations for the Interactive Cavity Preparation.

Variables Values Correlations

Mean Median SDa I1 I2 I3 I4 I5
I1 3.03 3.00 .720 – .115 .024 .209 .027
I2 3.84 4.00 .543 .115 – .125 .449* .020
I3 3.57 3.50 .643 .024 .125 – .343 .308
I4 3.19 3.00 .567 .209 .449* .343 – .258
I5 3.50 3.00 .948 .027 .020 .308 .258 –
a
SD = Standard deviation.
*
Correlation is significant at the 0.05 level (2-tailed).

positive, but also statistically significant at the 0.01 level. In the case of the Gross Anatomy 3D Atlas, the correlations for the same pairing of
variables are not as strong as in the case of the Panoramic Radiography application, but they are still positive and statistically significant at
the 0.01 level for the pair I1–I4 and at the 0.05 level for the pair I5–I4. These correlations become weaker for the Interactive Cavity Prep-
aration, which, while still positive, no longer present statistical significance.
Another set of variable correlations that complements the link between interactivity and learning outcomes is the pairing of variable I3
with I1 and I5, respectively. Variable I3, corresponding to question 3 on the questionnaires, measures the level of accuracy with which the
graphics employed in the applications represent the theoretical concepts related to the course subject matter. This variable registered the
highest mean value among all variables in the Panoramic Radiography questionnaire (4.05) and the second-highest mean value among
the variables for both the Gross Anatomy 3D Atlas (3.84) and the Interactive Cavity Preparation (3.57). The results show that there is a
positive and statistical significant correlation at the 0.01 level for the pairs I1–I3 and I5–I3 for the Panoramic Radiography Module. Regard-
ing the other two applications, the correlations are still positive (with the exception of a slight negative correlation between I1 and I3 for
the Interactive Cavity Preparation), but they are no longer statistically significant. Consequently, it can be asserted that the Panoramic
Radiography application has served the students’ needs better than the other two applications in terms of providing appropriate graphic
depictions of concepts that are conducive to learning.
At first glance, the mean and median values, and the pattern of correlations between variables suggest that the students considered the
interactivity levels built into the Panoramic Radiography Module to be the most effective in reinforcing learning concepts covered during
the course for which the application was developed. The interactivity embedded in the other two applications was considered less effective,
although the Gross Anatomy 3D Atlas did not lag as far behind the Panoramic Radiography Module as did the Interactive Cavity Prepara-
tion. On closer inspection, however, the differences in responses to the applications are not surprising and can be attributed to the extent,
complexity and depth of interactivity that the three applications displayed. The Panoramic Radiography Module is rich in content and con-
text, organized in three chapters including several testing scenarios, which allow students not only to manipulate content (i.e., view 3D
graphics animations, videos, simulations, etc.), but also to test their knowledge via built-in quizzes to specifically evaluate the level of
understanding that they reached by interacting with the content. The Gross Anatomy 3D Atlas, while presenting interactive features with
3D graphics, is more limited in content and allows for only basic testing of concepts learned. In contrast, the Interactive Cavity Preparation
(Fig. 4), an application built to simulate a clinical scenario, offers interaction with the content in a rather two-dimensional format. The
642 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643

absence of visual depth and the sensation of mimicking an actual drilling task by tracing colored lines on a flat surface may explain the
lower ratings it received from the learners.
Another, more subjective, explanation of the differences in the perceived effectiveness of the three applications may rest in the atti-
tudes toward and experience with digital learning objects that the two cohorts of students who responded to the questionnaires may
have had prior to their use of the applications. Thus, the DDS-III and DDS-IV students who provided feedback on the Panoramic Radi-
ography Module may have been more appreciative of the digital learning aids made available to them, since such tools had been em-
ployed sporadically during the course of their studies at the Faculty of Dentistry. In contrast, the DDS-I students may have been less
impressed by the digital applications to which they provided feedback, since they had been more accustomed to digital learning objects
and, generally, interactive tools prior to entering dental school. These subtleties in student attitudes toward digital learning objects were
not investigated expressly in this study, but they may factor into the differences of perception that the students exhibited towards these
applications.
In addition to the ratings that the learners assigned to each of the five questions on interactivity, there was a number of optional essay
responses recorded for each of the three applications. Table 9 shows a breakdown of the total number of respondents and the essay re-
sponses received per each application.
The essay responses revealed that the applications were generally used by the learners to test their understanding of concepts prior to
the exams in the courses which the applications served. Furthermore, the essay responses reinforce the findings in the correlations ana-
lyzed above in that the learners considered the applications, particularly the Panoramic Radiography Module and the Gross Anatomy
3D Atlas, as interactive, useful supplemental tools to review and learn specific concepts in their respective courses. Several quotes extracted
from the questionnaire responses would further illustrate the learners’ experience and perception of the applications:
‘‘Since the prof tested us on the material, it was a great resource for the test. It provided an interactive way to learn other than traditional
lecture based learning, which made learning more enjoyable. The animation allowed us to visually conceptualize the material.” (DDS-III
respondent #12 – Panoramic Radiography Module)
‘‘The module was very useful in helping me learn about panoramic radiology. It was easy to navigate through the different parts, and having
something this interactive to supplement lecture material is really helpful. I also thought the module was very good in covering the many dif-
ferent aspects and variations of panoramic radiology. A very helpful tool!” (DDS-III respondent #42 – Panoramic Radiography Module)
‘‘I felt that the 3d atlas helped to reinforce any problems that I was having from the lectures. Helped me to visualize some of the muscles/nerves/
bones and where they lie in relation to the head and neck.” (DDS-I respondent #18 – Gross Anatomy 3D Atlas)
While there was a general appreciation of and positive response to the development of the applications, the students also noted several
shortcomings. In the case of the Panoramic Radiography Module, they pointed to the problems in navigation from screen to screen or be-
tween the quizzes built into it. They also suggested that more testing should be included in the application. The most frequent complaint
regarding the Gross Anatomy 3D Atlas pertained to the amount of detail designed into the anatomical features of the 3D human specimen.
Furthermore, as DDS-I respondent #22 in the gross anatomy questionnaire put it, ‘‘the 3D atlas was easy to use and quite interactive, but
the concepts and topics covered were too simplistic. Nothing was covered in the amount of detail necessary for the anatomy course.” Sim-
ilar to the Panoramic Radiography Module, a number of respondents indicated that a larger number of case study questions would have
been useful. The four essay responses provided by the students in the Interactive Cavity Preparation questionnaire were inconclusive in
shedding more light on the experience the students had with that respective application.

5.6. Limitations of the study

While this study’s findings generally suggest that interactive features embedded into digital learning objects are conducive to learning,
there are some limitations that prevent direct generalizations of these findings across years or fields of study. However, extrapolations and
inferences can be made as to their applicability to other domains of learning, since the principles of interactivity included in these appli-
cations can be transferred to similar applications in other fields of inquiry.
One major limitation of the study is the relatively low response rate recorded for two of the applications, namely the Panoramic Radi-
ology Module and the Interactive Cavity Preparation, respectively. The cause of the low responses was simply driven by the amount of
time available to us after the administration of the exams in the three courses. Because the exams in Oral Radiology and Restorative
Dentistry were given approximately six weeks after the exams in the Gross Anatomy course, we had a longer window of opportunity
to gather survey data from students who used the 3D atlas than from students who used the Panoramic Radiography and the Interactive
Cavity Preparation.
Another limitation of the study stems from the reduced number of questions that could be deployed to investigate the students’ per-
ception of and experience with the applications. In an ideal scenario, an exhaustive questionnaire would have been developed and dis-
tributed to students in a face-to-face session. However, given the extremely dense and intensive study program that dental students
undergo, such a scenario was simply impossible to contemplate. Thus, a succinct questionnaire which probed the students on key as-
pects of interactivity and learning effectiveness had to be distributed online through Blackboard. In addition, despite repeated, periodic
calls for participation, the overall response remained low precisely because of the students’ more immediate needs to focus on their
studies.

Table 9
Essay responses received.

Application Number of respondents Essay responses Response rate (%)

Panoramic Radiography Module 55 23 41.8
Gross Anatomy 3D Atlas 44 20 45.5
Interactive Cavity Preparation 27 4 15.4
 F.D. Salajan et al. / Computers & Education 53 (2009) 632–643 643

6. Conclusions

We consider that the applications presented here fit properly in the general framework of interactivity described in the first part of the
article. The simple and straightforward three-way model of computer-initiated interaction proposed by Evans and Sabry (2003) is partic-
ularly suitable for the types of interactions that the three applications are designed to achieve. They contain many elements of interactivity
and 3D visual representations that can be latently effective tools for the enhancement of learning of specific concepts in the dental curric-
ulum. However, their use could be extended to other fields of the medical or health sciences. The Gross Anatomy 3D Atlas, for instance,
could be used with potentially beneficial effects in medical education. While the specific subject matter in the three applications is geared
to dentistry, the principles of interactivity built into the applications may also be transferred to other subjects outside the realm of health
sciences. Consequently, they may serve as models for the design of similar applications in other fields of study.
Regardless of the differences in the three student cohorts’ perception of the three applications, the data analysis from the preliminary
study presented here suggests that the levels of interactivity contained in the applications may be instrumental in reinforcing knowledge
and in fostering learning of complex concepts in dental studies. The ratings recorded for each of the applications revealed their distinct
ranking on an imaginary scale of effectiveness. Thus, the Panoramic Radiography Module was clearly perceived as the most effective appli-
cation in enhancing learning, through its combination of rich visual content, relevant context and an array of testing scenarios that con-
tributed to the deconstruction of complex concepts into simple and manageable units of knowledge. The Gross Anatomy 3D Atlas
trailed close behind, not because of the quality of the visuals or of the interactivity level, but mainly because the students considered that
the content could have been more extensive and the features of the human specimen more detailed. The Interactive Cavity Preparation was
rated lower than both of the previous applications, arguably because of the lower-end, rather flat visuals that accompanied the simulation
scenarios.
As part of a new cycle of development that begun in the summer of 2008, the three applications are undergoing a process of re-design
and improvements in both the visual interface as well as in the content that is presented to students. Apart from a new visual layout, new
interactive features will allow the learners to manipulate content and interact more freely with the 3D objects built into the applications.
The three applications, along with four others in different dental disciplines, will be provided with tracking tools in order to collect real-
time, statistical data about the patterns of use for these digital learning objects. In addition, the tracking tools will enable the present
authors to conduct further, more systematic research into the student experience with web-based interactive learning applications. This
future research should provide the opportunity to make more detailed and methodical interpretations of the effect of interactivity on learn-
ing over an extended period of time.

Acknowledgements

This project was made possible through grants from the Faculty of Dentistry Enrichment Endowment Fund and from the University of
Toronto Instructional Technology Courseware Development Fund, both for the academic year 2007–2008. The authors wish to thank the
creative team of developers including Usama Al-Riahi, Andrea Cormier, Matthew Dang, Neil Darbyshire and Devendra Dayal. We also ex-
press our gratitude to the media services team including James Fiege, Christine Nicolau and Bruno Rakiewicz. Finally, we hereby recognize
the invaluable contribution of the three cohorts of dental students that participated in this study.

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