Virtual Reality Training System on Oral Health Care for Dependency Elderly in Oral Hygiene Students: A Randomized Controlled Trial
Phase: NA
Conditions: Medical Education
Sponsor: Kaohsiung Medical University Chung-Ho Memorial Hospital

 
 
 
 
Virtual Reality Training System on Oral Health 
Care for Dependency Elderly in Oral Hygiene 
Students: A Randomized Controlled Trial 
 
 
NCT number: KMUHIRB-SV(II)-20200071 
Date: 2020/10/27 
 
 

Study protocol  
 
Background  
VR explores the revolution in medical training during COVID-19, when face-to-
face training is not possible during a nationwide lockdown. VR can ease the burden and 
train medical professionals much more effectively than the traditional training 
methodologies[1]. Virtual reality (VR) has been proposed as a promising technology 
for higher education since the combination of immersive and interactive features 
enables experiential learning. Medical and healthcare students have limited 
opportunities to practice such skills in their clinical placements due to a lack of 
supervision and relevant practicing situations[2]. At present, VR is regarded as a 
training tool that can effectively train and implement and has been widely used in 
professional medical operations[3]. A previous study found that a VR training system 
provided students with better learning outcomes and self-confidence[4]. VR may also 
help improved knowledge retention, increase motivation to study, and decrease the fear 
of learning new things[2].  
According to United Nations statistics [5], it is estimated that 15% of the 
population worldwide or some 1 billion individuals live with one or more disabling 
conditions. More than 46 per cent of older persons – those aged 60 years and over—
have disabilities and more than 250 million older people experience moderate to severe 
disability. Taiwan has reached an age society in 2018 and the elderly population 
accounts for 14.1% of the total population and is expected to enter a super-aged society 
in 2025[6]. Poor oral health gives rise to considerable problems that impact both on an 
individual's well-being and quality of life as well as increasing the risks of general 
health issues[7]. Studies have pointed out that providing professional oral care can help 
reduce the risk of respiratory infections in elderly[8, 9]. An intervention study from 
Japan suggested that providing professional oral health care (POHC) by dental 
hygienists reducing prevalence of fever and is effective in preventing respiratory 
infections in elderly persons requiring nursing care[10]. The oral hygiene students 
expect to become professionals who can provide oral care for the elderly in the future. 
In their development education, it is imperative to strengthen their oral care skills for 
the elderly. With the strengthening of their skills, they will increase their self-efficacy. 
Possess professional oral care for the elderly to facilitate the implementation of oral 
care for the elderly in clinical work in the future. Oral hygiene students should not only 
have the correct oral health care knowledge and skills but should further learn to be 
effective in the subsequent clinical practice or work in the correct choice of oral care 
instruments, demonstrating and teaching patients or caregivers how to perform oral 

health care properly, and then promote patient health care outcomes [11]. In addition to 
knowledge, there are also a series of operation steps and related equipment selection 
for the education and guidance of oral care. Therefore, it may be more difficult for 
students to have opportunities for self-operation and practice by simply teaching or 
demonstrating in class. Traditional physical teaching aids are also more challenging to 
simulate situations and even more challenging to have coherent step-by-step learning 
to overcome the difficulty of traditional teaching methods to achieve situational 
simulation and a series of practical exercises. 
VR, in particular, has been adopted across medical and nursing fields as a method 
to educate medical students on some professional topics that require operational 
learning, such as emergency first aid, basic life-saving techniques, surgical skills 
training, learning systematic clinical observation and fire safety; the results show that 
the effectiveness is no less than that of using traditional teaching aids, especially the 
effectiveness of operating skills [12-14]. No study has developed and evaluated the 
effects of implement VR applications to train oral care professionals. We therefore 
developed the first VR system used in professional oral care training, which allows 
users to self-practice the elderly oral care skill in an immersive and interactive cave VR 
system (Pvix VR, EPED Inc.). The dependency elderly seniors are selected as the 
training objects in this VR training system because they were high risks groups, and the 
elderly's safety cannot be guaranteed if the students have not undergone sufficient 
practice and training. Therefore, we aimed to evaluate the effectiveness of VR-based 
training on oral health care for the dependency elderly among oral hygiene students. 
Methods 
2.1. Design and Participants 
A randomized controlled trial (RCT) was conducted. The protocol was approved 
by the Institutional Review Board of Kaohsiung Medical University Hospital (reference 
numbers: KMUHIRB-SV(II)-20200071). All students provided informed consent 
before the participation. 
A total of 23 students from the third grade of Department of Oral Hygiene students 
in Kaohsiung Medical University during the 2021 academic semester were recruited in 
the present study. Participants have to take both the courses of 'Basic Medical Nursing 
Care' and 'Oral Health Care for Community People and Long-term Care Residents' 
before intervention. Eleven students were randomized in the virtual-reality 
experimental group (EG) and 12 in the control group (CG). 
2.2. Randomization and Allocation 
Students were randomly assigned to the virtual-reality experimental (EG) group and 
control group (CG). We used the random table from Excel with a ratio of 1:1 to 
accomplish the randomization. An open-label experimental design was used; students 

were wise to the group they were allocated in.  
2.3. Instrument 
A structured questionnaire related to elderly oral health was developed to collect 
data on five parts: (1) demographics (i.e., gender, age), (2) oral care-related knowledge, 
(3) attitude toward oral care, (4) self-efficacy toward oral care (5) intention to oral care 
behaviors. A panel of experts reviewed items to assess content validity. The content 
validity index was 0.97-1.00. The reliability of each scale was assessed in terms of 
internal consistency (Cronbach's alpha coefficient). The satisfaction survey was based 
on System Usability Scale (SUS) to measure the usability of the VR-based learning 
system the students used during the oral care training. The SUS covered the 
effectiveness ( the ability of users to complete tasks using the system, and the quality 
of the output of those tasks), efficiency ( the level of resource consumed in performing 
tasks), and satisfaction (users' subjective reactions to using the system) [15]. 
2.4. Outcome Measures 
2.4.1. Elderly oral care-related knowledge 
Twenty items measured elderly oral care-related knowledge; for example, 'There 
is no need to consider the size of the interdental brush.' Possible responses included 
True (1), False (0), and I do not know (0), with possible scores ranged from 0 to 20; a 
higher score indicated a higher degree of oral-care-related knowledge. The KR-20 
coefficient was 0.56 for this scale. 
2.4.2. Attitude toward elderly oral care 
Seven items measured attitude toward elderly oral care, for example, 'Assist 
disabled elderly to clean their teeth is annoying.' Each item was scored on a five-point 
Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Possible 
scores ranged from 5 to 35; a higher score indicated a more positive attitude toward oral 
care for the elderly. Cronbach's alpha was 0.70 for this scale. 
2.4.3 Self-efficacy of elderly oral care 
    Eleven items were used to evaluate the self-efficacy of elderly oral care. Students 
indicated their degrees of agreement with statements related to perceptions of personal 
ability concerning oral care for the elderly. For example, 'I am confident to remind 
disable elderly having regular dental visits every six months.' Each item was scored on 
a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). 
Possible scores ranged from 5 to 55; a higher score indicated more substantial 
confidence toward oral care for the elderly. Cronbach's alpha was 0.87 for this scale. 
2.4.4 Intention to elderly oral care behaviors 
    Twelve items were used to evaluate the intention to elderly oral care behavior for 
elderly. Students indicated their goals of adding new behaviors or modifying existing 
behaviors of oral care for the elderly. For example, 'I will take the initiative to assist 
disabled elderly to clean their dentures.' Each item was scored on a five-point Likert-
type scale ranging from 1 (strongly disagree) to 5 (strongly agree). 

2.4.5 Covariates 
    Age and gender were assessed at baseline for each student in this study. 
2.5. Interventions 
The VR-based training system (Pvix VR, EPED Inc.) equipped an optical portable 
wearable device that utilizes positioning motion recognition technology and a built-in 
virtual interactive software to assist in the self-training of future oral care personnel and 
health caregivers. Students are immersed in a 3D environment as soon as they put on 
the optical 3D glasses. The oral health interactive software stimulates diverse ability 
levels through the simulation of different actions. Students learn standard procedures 
of oral care through automatic assessment. In addition, the software customizes 
standard process courses and teaching plans in several fields.  
The students in EG received VR-based training for elderly oral health care at 2-
week (Time 2), 4-week (Time 3), and 6-week (Time 4) follow-ups. The learning module 
was divided into three sessions according to the physical condition (1) Mild disability, 
(2) Semi-disability, (3) Total disability and oral condition, (1) wearing dentures, (2) 
missing teeth of the elderly (Figure 2.). Students simulate the different physical and oral 
conditions of the elderly through virtual situations and provide suitable oral care 
methods. The whole training session took approximately two hours for each student; 
First, students were first given a short introduction to the VR system's use (10 minutes). 
Second, they were able to carry out oral care for the elderly while wearing VR goggles 
and using hand-controllers with the teaching and audio guides during the process (90 
minutes), and an evaluation was taken after the intervention (20 minutes).  
    The students in CG do not receive any of the interventions. However, the same 
VR-based curriculum of oral health care on dependency elderly were provided at the 
end of the study. 
2.6. Data Collection 
    The students in both groups self-completed a baseline questionnaire after the 
allocation. The post-test was collected immediately after each intervention, and the 
satisfaction survey was collected at the end of the whole intervention in the 
experimental group. As for the control group, the post-test was collected at 2-week 
(Time 2), 4-week (Time 3), and 6-week (Time 4) follow-ups. 
 
 

Statistical Analysis Plan 
 
This study explored the variables' relationships using STATA version 13.1 (Stata 
Corp LP, College Station, Texas, USA). Percentage, Fisher's exact test, and Wilcoxon 
rank-sum test were used to compare the VRG and CG demographic variables. Wilcoxon 
rank-sum test compares the difference of oral care-related knowledge, Attitude, self-
efficacy, and intention within groups. Linear regression in generalized estimating 
equations (GEE) compares the difference of oral care-related knowledge, attitude, self-
efficacy, and intention between groups. The effect size (Cohen's d) of continuous 
variables were calculated from the mean difference between baseline and the follow-
ups between the VRG and CG. An effect of 0.20 is small, 0.50 is medium, and 0.80 is 
large[16]. 
 
 
Figure 1. CONSORT flow diagram