Dental News - “Understanding the learning process ourselves helps us teach others how to learn properly”

Anisha Hall Hoppe, Dental Tribune International

Fri. 10. February 2023

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Dr Przemysław Kustra has spent decades not only in honing his craft as an endodontic specialist but also in perfecting the art of teaching. Specifically, Dr Kustra has used his research in endodontics as a portal to explore ways to improve didactics, abandoning traditional methods and replacing them with insight into advances in additive manufacturing that give his students the opportunity for deeper learning on 3D-printed teeth and dental structures that exactly match those featured in complicated casework. Dr Kustra spoke with Dental Tribune International about how he has used technology to advance teaching.

Dr Kustra, could you share with our readers how you identified the need for researching the use of 3D models in endodontics?
Thanks to my almost 20 years of working as a researcher and teacher in the Department of Conservative Dentistry and Endodontics at the Jagiellonian University Medical College in Kraków in Poland, and because of my PhD in endodontics, I have a clearer and deeper understanding of certain aspects of teaching, and I take the transfer of knowledge very seriously.

I remember, while still a student at my first international conferences, watching examples of beautifully executed root canal treatments, including extremely difficult clinical cases with successful outcomes. I learned that even the most difficult clinical cases could be dealt with through the use of good models. Such models would require the new technology that began to appear in those years. Specialist equipment, working techniques and the development of effective treatment methods were what drove me on because I was very interested in the effective treatment of dental diseases. I decided that, as a teacher, I would conscientiously pass on the skills and knowledge entrusted to me by previous generations.

I realised an additional teaching approach was necessary, one which would accelerate the acquisition of clinical experience while enabling the student to gain self-confidence in performing clinical procedures effectively. An example would be the clinical rinsing of a root canal, during which an assistant demonstrates the procedure and the student observes the technique via a separate monitor, after which I perform the procedure myself. At a later stage, a surgical microscope is used to demonstrate the root canal rinsing procedure, so that the student can clearly see how resulting dentine chips are successfully removed and rinsed away. When a microscope is used in work from the beginning, the effects of the procedure can be viewed directly. Usually, root canal rinsing is moderately effective in removing impurities, but the technique can be quickly improved and corrected. For the casual observer, nothing changes at all, as the rinsing operation looks unchanged, but something subtle and yet sufficiently effective must have happened so that the canal is now rinsed and cleaned properly. When we have the opportunity to see our work, we can immediately correct it by means of our working technique.

Dr Przemysław Kustra.

Examples of 3D scans provided by Dr Kustra of his own face. Taken with a Siemens Somatom Sensation Cardiac 64 spiral CT scanner, such images are useful for virtual endoscopy planning.

Dr Kustra demonstrating the use of a Leica HM 500 digital microscope for his students.

“When we have the opportunity to see our work, we can immediately correct it by means of our working technique.”
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A valuable teaching technique is the use of a copied tooth by a student or clinician to create a realistic clinical situation that will give the student the opportunity to gain experience in performing the procedure effectively and with confidence. This removes the need of the help of an assistant who normally helps students from start to finish, from the opening of the tooth chamber, right through to the task of root canal sealing.

Using 3D printing allows students to work with multiple exact copies of teeth for specific clinical situations. A teaching assistant presents the procedure using the first model, then, on the next model, the students can perform the procedure on their own, improving their working techniques until they are sure that they will be able to perform the procedure on the patient’s tooth from beginning to end.

What suggestions could you offer to clinicians who have been practising for a long time but who are not yet comfortable with incorporating more digital processes into their workflow?
3D printing itself is interesting and the ability to create draws you in. We can plan, create and print real models that improve treatment outcomes and present patients with real visuals.

The basis of a doctor’s thinking is to find a way of treating diseases in a satisfactory way. This always leads to caution when applying new techniques, specifically concerning the materials or devices used. When it comes to devices, it is always a question of whether the cost of the device will actually improve the health of my patients.

A 3D printed lower incisor used in instruction.

A digital model being prepared for a virtual endoscopy.

A 3D printed molar as viewed by a student under a clinical microscope.

Were there any results that surprised you, or additional areas of research that you identified?
When it comes to 3D printing, it is the innovative character and attractiveness of the technology that counts. I noticed that students like new technologies, and this was a factor that stimulated their desire to study. Everyone wanted to be in the group doing research involving 3D printing, to the point that additional research groups had to be organised.

The use of 3D printing also presents the opportunity for colleagues to help one another in a given field. For example, a dentist in possession of a patient’s radiograph could bring a printed tooth to a conference or to a specialist and could, together with others, develop a technique for the procedure before commencing clinical work. This is most likely to happen in complicated cases.

While working with 3D-printed models, I found that students did surprisingly better when working with premolars than with molars or incisors.

Where would you direct clinicians who want to learn more about the topics of bioprinting and virtual endoscopy?
There are many 3D dental atlases available today, and their databases are constantly being improved. You can familiarise yourself with the available programs for virtual endoscopy on medical industry websites. Medical physics departments also deal with this topic in the context of engineer training. One example of open-source software is InVesalius.

In addition, studying 3D bioprinting is worthwhile. This is a technique mainly associated with reconstructive surgery techniques, and is the future for personalised oral soft-tissue regeneration. It is also designed to deal with challenges involved in regenerative dentistry by fabricating 3D tissue structures with a customised complex architecture. CELLINK and Fluicell are fairly well-known educational platforms as is the edX platform, which has courses in subjects such as biomaterials and biofabrication.

“Our students are our future.”
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How has training for students changed in the last ten years, and what do you predict dental and endodontic training will look like in the future?
Our students are our future. Practice, practice, and even more practice makes perfect. Habits established early may last for years so, it is good to start with the best ones. If the teacher is very skilled, it’s more likely that the student will also become very skilled.

The changes in training come down to the amount of time allocated to theoretical and practical learning. I have also noted that there is a significant need for practical classes in order to acquire manual skills. With these classes, there has been a shift from block classes to year-round classes. Constant practice is important, as is the ability to make positive demands and reduce routine. These changes have been followed by the implementation of machine working techniques, together with the implementation of electronic measurement and root canal filling devices. We have worked to make seminars more interactive with open discussion of problems and the differences of perspective between authors.

Additionally, even though disease is objectified in instruction, it is important to be sensitive to the views of others in order to avoid treating a person as an object.

A tooth about o be inserted into a Nanotom scanner for radioisotope thermoelectric generator (RTG) scanning.

The Nanotom scanner, running radioisotope thermoelectric generator (RTG) scans on a single tooth. With the scans, a digitial model can be made and the data generated can be further used for other purposes such as bioprinting.

“...a clinician with extensive clinical experience...can, during the mechanical preparation of a root canal, ‘teach’ the system.”
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In the future, we may become aware of the strengths and weaknesses of the use of artificial intelligence in procedures. As an example, a clinician with extensive clinical experience working with an endodontic motor equipped with artificial intelligence can, during the mechanical preparation of a root canal, “teach” the system. The dexterity gained by that clinician over the years in his or her hands through manual work can be digitally transferred to the program. For the dentist who uses this device, it will be easier to perform subsequent treatments. Such devices would have to be equipped with an endometer that continuously measures the working length of the root canal. The data obtained could be shared with other clinicians who would be able to download this data to their endodontic motors. This would allow even novice dentists to be able to treat patients more effectively.

There will still be some instances where, even with the use of technology during the teaching process, manual precision will be required, as well as time to create neural connections in the brain of the learner. Just as in sports we witness that, through continuous exercise, the athlete achieves better and better results. We may perform more poorly as we initially form and restructure neural connections, but being aware of that fact will help us better understand it, and this will benefit everyone. Understanding the learning process ourselves helps us teach others how to learn properly.