Conflicts are part of the life of any organization, and the dental professions are not spared. Jurisdictional battles and supremacy struggles are not alien to dentistry [1]. Unfortunately, despite the obvious reported benefits of interprofessional education (IPE) for interprofessional collaborative practice (IPCP) [2], there is a paucity of data about IPE to promote IPCP among dental professionals. Dentists and dental technicians need to communicate effectively and contribute their professional skills to ensure that they make decisions that are in the best interests of their patients [3]. A clear understanding of the interactions of the dental care team can promote teamwork [4], establish cooperative goals [5], encourage mutual respect [6], and promote IPCP between dental students and dental technology students [7].

IPE encourages teamwork among dental care professionals [8-11] and is increasingly becoming a part of the training programs for dental and dental technology students [12-17]; however, gaps still remain. Perhaps, the largest gaps are owing to the predominant focus of previous studies regarding IPE and IPCP on student and instructor perceptions and a lack of objective assessment of collaborative practice as an outcome measure [18,19]. This marked gap has necessitated the development of a conceptual framework to evaluate the impact of IPE on IPCP to strengthen the evidence for IPE as a tool to improve IPCP between dental and dental technology students [20].

The objective structured clinical examination (OSCE) is an assessment tool based on the principles of objectivity and standardization, in which individual students move through a series of time-limited stations in a circuit for the purpose of assessment of professional performance in a simulated environment. At each station, the student is assessed and marked against standardized scoring rubrics by trained assessors [21]. OSCE has been widely adopted as a summative assessment in the medical undergraduate curriculum and is universally accepted as the gold standard for assessing clinical competence in dental education [22,23]; furthermore, its effectiveness has been confirmed by several studies [24-26]. On the basis of the extensive application of OSCE, the interprofessional OSCE (iOSCE) was initially developed to simulate IPCP [27]. Unlike conventional OSCE, iOSCE involves students from different professions, encourages students to work as a team, and requires the entire team to participate in all tasks [28]. This is performed to objectively evaluate the results of IPE. Within this framework, several variations of iOSCE have been developed to accommodate the training needs of health care teams built to address different disease categories (team OSCE [29,30], group OSCE [31,32], interprofessional team OSCE [28,33], etc). These iOSCE variants can be roughly divided into synchronous [33-36] and asynchronous [29,37] task-based variants. A team working in an operating room typically works synchronously, whereas health care teams of dentists and dental technicians typically work asynchronously. Although the use of iOSCE in medical education has been extensively reported [27-30,38-42], to the best of our knowledge, the use of iOSCE for asynchronous work, especially within dentistry and dental technology cross-professional education, has not been reported.

Although iOSCE may provide an ideal solution for dental and dental technology students to perform IPCP simulation based on real patient cases, the COVID-19 pandemic [43] highlighted the limitations of this traditional approach. For example, a plaster model generated from a clinical case and passed multiple times among students and examiners may pose a risk of infection. In addition, diagnostic stations are usually set up to facilitate OSCE. A station is typically equipped with a trained, standardized patient, and the students complete the diagnosis by asking questions and examining this standardized patient. The risk of infection at this type of station was heightened during the pandemic. Nevertheless, compared with the traditional OSCE, iOSCEs are more time consuming and resource intensive [44,45], especially in dental education; hence, a virtual approach, as developed and piloted in this study, is justified [46,47]. Notably, the conventional virtual OSCE (vOSCE) has been described as a method of performing OSCE using internet technology in medicine [47-49]. The major reason for this technological approach was the scattered nature of the locations of students requiring assessment. However, this approach does not fully leverage virtual technology in dentistry. The integration of digital dental technologies and cloud-based dental laboratory workflows could be practiced within the vOSCE framework [50], which now also forms a professional core course in dental technology education [51-53]. The development of iOSCE based on virtual technology could facilitate the inclusion of digital dental technology in the blueprint design of examination stations. This combination could simulate the critical needs of present-day dental laboratories and promote students’ improved perception about the current demands of the profession.

To address these research gaps, this study presented a new virtual iOSCE (viOSCE) to objectively assess the effectiveness of IPE as a tool to promote IPCP among dental and dental technology students. We have described the development and piloting of a viOSCE framework and its virtual techniques to validate the user-friendliness of IPE and document its effect on IPCP among dental and dental technology students. Data from both subjective and objective evaluations were collected, and their correlation was assessed.

The principal investigator (PI) first limited the viOSCE knowledge to content related to the prosthodontics course. Content related to implantology and orthodontics was excluded because it is not part of the core undergraduate coursework for dental or dental technology students. On the basis of the Association for Medical Education in Europe guide [54], a modified Delphi method was used to generate content for viOSCE. The Delphi method is a decision-making process that uses expert opinion, gathered in the form of a survey, under the guidance and direction of the PI to reach group consensus through collaboration, independent analysis, and iteration [55]; this process is the most frequently used method to generate content for OSCEs [54]. The panel of experts in this study consisted of 9 instructors (including the PI) from the College of Stomatology, Chongqing Medical University. All 9 instructors had prosthodontics teaching experience and digital technology practical teaching experience with undergraduate dental and dental technology students. They had also participated in the design and examiner training for traditional OSCE, but only the PI had experience in IPE and vOSCE design.

In this study, there were 4 iterations (rounds) before the viOSCE station design was finalized. In the first round, the PI identified 10 potential topics for viOSCE based on the syllabus of the prosthodontics course for dentistry and dental technology students, gave initial suggestions for the station design, and created a manuscript that was emailed to the panel of experts. Each expert independently gave their opinion and selected 5 topics that they considered as the most important in the syllabus and the most suitable for assessment using viOSCE. In the second round, the PI identified 3 topics with the highest selection rate based on the expert feedback and designed draft blueprints for 20 stations based on the top 3 selected topics using existing virtual technology support. These were sent to the expert panel via email. The expert panel commented about the potential effectiveness of interprofessional collaboration at the stations, made necessary corrections, and returned the design drafts to the PI. In the third round, the PI summarized all the changes made by the expert panel and, finally, decided on 7 stations based on the availability of virtual technology and the time to be spent on the stations within the allotted time frame of the examination. Stations consuming a lot of time, requiring multiple devices for support, or requiring very large spaces were rejected. Next, the selected viOSCE station blueprint design was completed, the virtual technical support was finalized, and the PI sent the final viOSCE station blueprint to the expert panel via email. The expert panel created the scoring rubrics based on the final viOSCE station blueprint, and these were returned to the PI for finalization. In the final round, the PI compiled all the information and met with the group to get a consensus regarding the viOSCE station blueprint and scoring rubrics. Once all the experts approved the viOSCE test station blueprint and scoring rubrics, the PI declared the viOSCE design as complete and declared the panel of experts the viOSCE examiner panel (Figure 1).

The developed viOSCE framework consisted of 3 topics, namely, fixed prosthodontics, removable prosthodontics, and clinical diagnostics. There were 7 collaborative examination stations consisting of 4 asynchronous and 3 synchronous stations. All these stations were designed and developed using the Delphi method (Figure 2).

At the fixed prosthodontic stations, the dental student prepared tooth 8 (maxillary right central incisor) on the simulator (Nissan Dental Products) and then worked with the dental technology student to scan the preparations using an intraoral scanner (Panda P2; Freqty Technology). The dental and dental technology students at the intraoral scanning station worked collaboratively. The dental student performed an intraoral scan task, and the dental technology student observed the scan results to determine whether they could be used for the computer-aided design (CAD) wax pattern station. After obtaining a digital model, the dental technology student used a CAD system (Dental system; 3shape) to design a single crown on the digital model of the preparation. Individual scoring rubrics were designed for tooth preparation, intraoral scan, and CAD wax pattern. The 3 examiners scored each of the 3 stations (Figure 3 and Tables 1-3).

At the removable prosthodontics station, real patient cases and intraoral digital models were selected and prepared by the PI, followed by approval by the expert panel. The intraoral digital model was a clinical plaster model scanned using Lab Scanner (E4; 3shape). Each dental student used our previously developed Objective Manipulative Skill Examination of Dental Technicians (OMEDT) system [56] to observe the intraoral digital model and to design a removable partial denture (RPD) framework. At the end of the design task, the dental student submitted the design and then discussed the design with the dental technology student; the dental student could make modifications if they wanted to. Next, each dental technology student used a CAD system (Dental system; 3shape) to design the framework of an RPD on the intraoral digital model based on the final design. A viOSCE examiner scored the first RPD design using the OMEDT system. Next, the viOSCE examiner scored the final RPD design and the digital framework of the RPD. The design discussion station was not scored by a separate examiner (Figure 4 and Tables 4 and 5).

The clinical diagnostics station used a virtual standardized patient (VSP) with the haptic device (UniDental, Unidraw). The VSP hardware does not have an anthropomorphic shape, but it interacts through vocal, visual, and haptic devices. On the basis of the novel oral knowledge graph and the coupled, pretrained Bert models, the VSP can accurately interact with a dentist’s underlying intention and express the symptom characteristics in a natural style [57]. On the basis of this algorithm, the PI adjusted and entered the real patient case details, allowing the dental technology student to work with the dental student as a chairside dental technician to make a diagnosis based on the information obtained from the interactions with the VSP. In this study, the clinical case designed on the VSP was a patient who required root canal treatment and full crown restoration. At the end of the dental student’s diagnosis and simulation, the dental technology student was required to assist the dental student in designing the restoration plan and help the patient in choosing the materials for crown restoration (this often determines the price of the treatment). Thus, dental and dental technology students finalized the prosthodontic treatment plan collaboratively. The visual device built a virtual dental clinic environment and VSP model, allowing the students to view the VSP from global, extraoral, and intraoral perspectives. The haptic device allows dental students to perform intraoral and extraoral examinations using essential tools to explore the diagnostic evidence.

Owing to the complexity of collaborative diagnosis, the station was manually scored by 2 examiners independently based on the previously developed scoring rubrics, whereas the UniDental output machine provided an additional score according to the previously developed scoring rubrics. The average of the 3 scores formed the final score for the station. To ensure the relative independence and internal consistency of all scores, the examiners were not informed about the existence of the machine score. The PI exported the machine score data from the VSP at the end of the experiment (Figure 5 and Table 6).

In this study, fourth-year undergraduate dental students and third-year undergraduate dental technology students participated in viOSCE because students at this stage of education had completed preclinical professional training. Overall, 50 students who met these requirements, including 25 (50%) dental students and 25 (50%) dental technology students, were recruited into the viOSCE user evaluation experiment and were divided into groups of 2 comprising 1 dental student and 1 dental technology student. The PI and examiner teams did not influence or determine the team-formation process. All participating students were informed that as this viOSCE was in the experimental phase, it was conducted as a small extracurricular skills competition, thus allowing for self-evaluation without a final examination situation, as previously reported [58]. This approach allowed for the simulation of an examination situation without affecting the final examination grade of the students. A month before commencing the experiment, the PI led an web meeting for students to explain the viOSCE, the relevant knowledge points, and the need to practice fully during the upcoming month. At the end of the meeting, the students completed the Readiness for Interprofessional Learning Scale (RIPLS) pretest questionnaire, which is a 19-item 5-point Likert-scale questionnaire; this type of questionnaire is the most frequently used method for the subjective evaluation of IPE and IPCP [18].

viOSCE was piloted after the 1-month preparation period. The panel of examiners marked points according to the previously prepared scoring rubrics, whereas some of the points were automatically scored by a machine. After this step, the participating students completed the posttest self-made questionnaire, to which a mutual evaluation scale and a viOSCE evaluation scale were added. The mutual evaluation scale asked the students to score the performance of their partner, whereas the viOSCE evaluation scale asked the students to score viOSCE. In total, 6 items were included in the mutual evaluation scale, and 7 items were included in the viOSCE evaluation scale (Textboxes 1 and 2). All items in both questionnaires were set to a maximum score of 100. Before issuing the questionnaire, the panel first reviewed all the questions, clarified ambiguities, and removed any double-barreled questions [59,60]. At the end of the experiment, one-on-one interviews were conducted with all the students to determine their perceptions about viOSCE.

Data were tabulated in a Microsoft Excel spreadsheet and imported into IBM SPSS Statistics for Windows (version 26.0; IBM Corp) for descriptive analysis. GraphPad PRISM 8.0 software (GraphPad Software) was used to create the graphs. Responses were summarized, and comparisons were made. Output data were presented as percentages and in graphical format. The Shapiro-Wilk test was used to test for normal distribution. Specific data analysis tests performed included descriptive statistics, 2-tailed paired t tests, and correlation analyses.

The research ethics committee of the Affiliated Hospital of Stomatology, Chongqing Medical University, approved this study protocol (COHS-REC-2022; LS number: 096). All participants provided written informed consent before participation in the study.

The IPCP results of dentists and dental technicians reflect the quality of their IPE, skill training, and clinical experience. The results contribute to the much-needed IPE assessment literature and suggest that teamwork skills can be improved by IPCP and effectively assessed using this new evaluation scale. We used a modified Delphi process in this study. This is in accordance with Simmons et al [27], who found that the modified Delphi process is an effective tool to obtain consensus among professionals for the foundational work required. In addition, our study demonstrated the effectiveness of iOSCE in asynchronous and synchronous collaboration scenarios, while providing a methodological reference for developing a new iOSCE for dental health care professionals. As the collaboration scenario between the dentist and the dental technician may be both asynchronously applied through prescriptions and synchronously conducted in chairside discussions [61-63], it was deemed appropriate for the viOSCE framework to consider both synchronous and asynchronous scenarios.

The viOSCE scores in this study also reflect the effectiveness of the framework design. From the viOSCE examiner scores in the fixed prosthodontics section, a significant positive correlation between the scores of the tooth preparation station and the CAD wax pattern station was evident. This finding is consistent with the actual clinical asynchronous delivery scenario, where the dentist’s preparation largely determines the quality of the dental technician’s crown wax pattern. Qualitative evaluations extracted from the one-on-one interviews also supported this result. For the removable prosthodontics section, the negative correlation between the scores of the RPD design station and the CAD wax pattern station was not statistically significant, which might be owing to the fact that more than half of the groups (15/16, 94%) worked collaboratively to modify the RPD design to possibly compensate for the lack of training, which is consistent with the findings about dentists’ inadequate competence in RPD design reported in other studies [64,65].

As OSCE is essentially a simulated scenario-based examination, the use of virtual technology to build simulated scenarios has become an important direction for OSCE-related studies, especially in the field of dental education [43]. The COVID-19 pandemic has further contributed to dental educators’ interest in this area, as dental clinical practice typically occurs in a virus-laden aerosolized environment [66]. Therefore, providing a safe and robust learning environment in the simulation clinic is also critical to help students compensate for lost educational time. The virtual technologies used to construct the simulated clinical environment in this study include VSP and CAD. Previously, Janda et al [67] developed a virtual patient as a supplement to standard instruction in the diagnosis and treatment planning of periodontal disease. However, it could not fully understand complex or ambiguous questions, and the students felt frustrated during the practice [67].

Tanzawa et al [68] developed a robot patient that could reproduce an authentic clinical situation and introduced it into OSCE. However, the dialogue recognition of the robot patients was prespecified; the robot was unable to identify subjective patient descriptions or the dentist’s interrogation intention and could not support intraoral or extraoral examinations to obtain diagnostic evidence [68]. To fill these gaps, our study used VSP with intention recognition and haptic feedback to construct virtual dental clinical practice and diagnosis scenarios more realistically. As the diagnostic evidence collected by students through interrogation, inspection, and palpation was automatically summarized for the final differential diagnosis, and omissions in the examination process eventually led to a misdiagnosis, the system simulated a high-fidelity clinical environment. In addition, the results showed that 1 (6%) of the 16 student groups misdiagnosed their VSP because of incomplete interrogation and palpation. The correlations between the scores of the 2 examiners and the machine scores were statistically significant, thus confirming the robustness of the high-fidelity simulation scenarios constructed by the VSP and the machine scores. On the basis of these results, the use of VSP should be expanded and integrated into daily teaching to give students more opportunities for clinical practice training.

Consistent with the results of previous OMEDT studies [56], the use of CAD technology in viOSCE significantly reduced the time spent at each station for the dental technology students. Some dental technology students complained about the slowness of the CAD program. Upon further investigation, it was found that they imported both impressions at the same time. In dental laboratory practice, dental technicians usually import the impressions separately to prevent computational issues. This finding exposes the lack of virtual dental laboratory practice skills in teaching, which needs to be addressed.

The results showed that the teamwork and collaboration subscale scores were significantly increased at the end of the study (P=.004), suggesting that viOSCE can improve students’ teamwork skills. The increase in the other 3 subscale scores, although not statistically significant, can be explained by the choice of timing of viOSCE. The optimal time to expose medical students to IPE is still subject to debate [18]. viOSCE, as a clinical IPCP intervention introduced during the clinical year, had no significant effect on the promotion of negative or positive identity or roles and responsibilities. This finding may be due to the fact that the students’ professional cognition had been stereotyped at this time, making it difficult to effect significant changes through IPE or IPCP intervention. This conclusion is supported by a previous study [69].

The results of the mutual evaluation scale showed statistically significant difference in participant motivation between the 2 professional groups, which could be explained by the results of the roles and responsibilities subscale. Of the 16 dental technology students, 4 (25%) expressed that they would not practice as dental technicians in the future because they wanted to choose other careers. The differences in the scores of the other items were not statistically significant, thus showing the effectiveness of viOSCE in the development of teamwork spirit. This result confirms that the OSCE design is well suited as a final evaluation of IPE and IPCP. In addition, the average score of each item of viOSCE was >60, indicating that the students were satisfied with the design and operation of viOSCE. The differences in scores between the 2 types of professionals were not statistically significant, except at the removable prosthodontics station, which was probably caused by the dental technology students’ unfamiliarity with the CAD program.

Overall, the internal consistency of all subjective evaluations was acceptable, and the results met expectations. Interesting observations were also made regarding the correlation between the subjective and objective evaluations. The SD of the scores on the mutual evaluation scale showed a decreasing trend among the dental and dental technology students with higher viOSCE scores and those with lower scores, but an increasing trend in the median score was observed. Although this trend was not statistically significant due to sample size limitations, this early finding provides data support for a summary of clinical experience published previously by Preston [70], who reported that the intensity of the relationship between dentists and dental technicians is determined by the difference in their professional skills. If the professional skills of both parties are high, there will be few problems in their cooperative relationship. The more discriminating and demanding the technician or dentist becomes, the more the relationship is strained when either fails to perform up to the other’s standards. This result suggests that in the study of IPE and IPCP for dentists and dental technicians, it is not sufficient to explore the improvement of the traditional assessment dimensions such as team collaboration skills and identity. The final quality of the output must be included in the assessment dimension. This also reaffirms the effectiveness of viOSCE as an objective, quantitative evaluation tool for IPE and IPCP.

The main limitation of our study is the small convenience sample of participating students, which could have led to self-selection bias. The sample size should be expanded in the future to obtain more data and to further verify the robustness of the viOSCE framework. In addition, whether viOSCE should be made a part of the large and more complete OSCE to test the ability of students to meet undergraduate graduation requirements will also be the focus of our next study. Moreover, the independent application of the novel VSP in the education of dental students is an interesting topic that will be explored in the next step of this study.

On the basis of our results, we provide the following recommendations:

In this study, a novel viOSCE framework was developed and piloted. Data based on subjective evaluation scales and objective examiner scores were collected and analyzed, confirming the effectiveness of viOSCE as an objective evaluation tool for IPE and IPCP. The experimental design should be expanded to include more randomly selected students with a scientifically determined sample size to further develop studies focused on IPE and IPCP in dentistry and dental technology, ultimately promoting quality in dental clinical practice.