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European Journal of Dental Education ISSN 1396-5883

Evaluation of a blended learning course for teaching oral radiology to undergraduate dental students A. Kavadella1, K. Tsiklakis1, G. Vougiouklakis1 and A. Lionarakis2 1 2

School of Dentistry, Athens University, Athens, School of Humanities, Hellenic Open University, Patras, Greece

Keywords dental education; blended learning; dental radiology; students’ attitudes; educational effectiveness. Correspondence Dr. A. Kavadella 46, Ilektras Apostolou St. 14121 Heraklion Athens, Greece Tel/Fax: 00 30 210 2829387 e-mail: [email protected] Accepted: 22 December 2010 doi:10.1111/j.1600-0579.2011.00680.x

Abstract Aims: The purpose of this study was to develop and implement a blended course (a combined face-to-face and online instruction) on undergraduate oral radiology and evaluate it by comparing its educational effectiveness (derived from students’ performance and answers to questionnaires) to a conventional course’s. Students’ attitudes concerning the blended methodology were also registered. Methodology: An original course was developed and implemented, and its electronic version was uploaded to an e-learning educational platform. The course was attended by two groups of final-year students, who were taught by either the conventional faceto-face methodology or the blended learning methodology. Students answered a series of questionnaires, before and after following the course, regarding their perceptions, attitudes and evaluation of the course. Additionally, they completed knowledge assessment tests and their grades (before and after the course) were compared. Educational effectiveness of the course was determined by analysing the results of the questionnaires and the tests. Results: Students in the blended group performed significantly better than their colleagues of the conventional group in the post-course knowledge test, and female students of the blended group performed better than male students. Students evaluated high the course content, organisation, educational material, and the blended group students additionally appreciated the course design and clarity of instructions. Students’ attitudes towards elements of blended learning (effectiveness, motivation and active engagement) were very positive. Most of the blended group students, who attended the face-to-face meeting (approx. 91%), evaluated it as helpful for summarising the subject and clarifying difficult issues. Conclusions: Blended learning is effective and well evaluated by dental students and can be implemented in undergraduate curriculum for teaching oral radiology.

Introduction Computers have entered our lives and changed them forever. The rapid technological advancements and the introduction of information and communication technologies (ICT) have permanently altered our economic, social, professional and even personal lives. Our society is now information-driven. As society is changing, our education methods cannot remain

static but must be dynamic and responsive to the wider social environment (1). The education systems worldwide are undergoing enormous changes, as courses and programs are designed in new ways and with new educational content, which includes the most updated knowledge and sets a base for the easy incorporation of the future knowledge. Particularly in the higher education area, it was characteristically stated that ‘integrating teaching, learning and technology is a mandate, not an option, ª 2011 John Wiley & Sons A/S

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and doing any less would border on professional irresponsibility’ (2). From the pedagogical point of view, electronic education has the potential to shift the paradigm from passive teacher-centred learning to active learner-centred learning (3). E-education has progressed in recent years to a new approach in the form of blended learning. Blended learning combines (blends) the use of the online learning with traditional classroom-based learning. The main advantage of blended learning is that it integrates the strengths of synchronous (face-to-face) and asynchronous (web-based) learning activities (3, 4), by dichotomising the total class time into a distance or a web-based learning portion and an in-class or face-to-face meeting portion (5). The length of each learning mode may vary according to the course design (5). The establishment of a balance between the face-to-face education and the online environment is a challenging process, depending on factors such as the instructional objectives, the characteristics of students, the condition of online resources and the trainer’s experience (6). The literature offers a number of definitions of blended learning which refer to the blendedness of media or pedagogies or even interaction. In the present study, blended learning is considered as an educational methodology, where online learning is blended with traditional instruction and the online portion of the course replaces part of the classroom time (reduced seat time).

Reasoning and aims of the study Dental schools are beginning to support face-to-face teaching using online educational tools (3). Dental students are increasingly being exposed to new digital learning technologies particularly those delivered online thus challenging the traditional lecture and clinical settings. In various countries and institutions, they are being exposed to webcasting and portable digital assistants, online assessment, electronic databases and virtual libraries, video-assisted clinical instruction, online discussions and collaboration, blended delivery, clinical simulators and virtual reality (7). Research studies, concerning the development, implementation and evaluation of online and blended courses in the dental curriculum, have been performed on many disciplines, such as, undergraduate (8) and postgraduate orthodontics (9), anatomy (10), oral pathology (11), fixed (12) and removable prosthodontics (13), radiological anatomy (14), restorative dentistry (15), dental terminology (16) and health informatics (3). These studies are investigating the students’ perceptions, expectations, performance and evaluation of the courses, the educational effectiveness of the course or modules, the course design and delivery, and the teachers’ attitudes and opinions. They report positive outcomes concerning the efficacy and acceptance of the e-courses, but more research is required to evaluate the application of these new educational methods in dental education. The purpose of this study was to develop and implement a blended course (a combined face-to-face and online instruction) on undergraduate oral radiology and evaluate it by comparing its educational effectiveness (derived from students’ performance and answers to questionnaires) to a conventional

Evaluation of a blended learning course

course’s. Students’ attitudes concerning the blended methodology were also registered, as their attitudes (together with their opinions and evaluations of the course) are considered essential in establishing the success of a blended course.

Materials and methods The subjects in this study were 47 students of the 10th semester (final year) in the School of Dentistry of the University of Athens. Students enrolled in the course on a voluntary basis, after been informed about the purpose of the study and that they would acquire a more extensive knowledge on the specific subject, which is considered to be one of the most challenging subjects in oral radiology. At first, students were assigned to each group randomly, but problems occurred when students who had no/limited access to a computer, or no experience/ sufficient knowledge in computer manipulation were assigned to the blended group, thus a trade-off had to be made, which compromised the randomness of the procedure. Nevertheless, this swap was necessary, as the students who participated in the blended group had to have sufficient computer knowledge to access the e-course, send and receive emails, and perform literature research, etc. The course was entitled ‘Differential diagnosis of mixed radiolucent-radiopaque bone lesions’, and it focused on the differential diagnosis of the lesions based mostly on their radiographic image and less on their clinical and histological images. The course was developed especially for this study; it did not replace any existing course in the curriculum (instead, it complemented and improved the relevant brief lecture), and it was taught on top of the students’ schedule, at pre-agreed weekly hours where they had no other obligations. Effort was made to provide the same depth and width of information to the two groups, by uploading the same PowerPoint presentations and additional notes to the educational platform as those presented in the conventional classroom lectures. The content of the course, as presented in the PowerPoint presentations, included (i) classification of the lesions, (ii) explanatory schematic drawings, (iii) brief description of the characteristic features of the lesions, (iv) summary tables, and (v) numerous radiographic images of different techniques (panoramic, periapical, occlusal and CT, etc.) where lesions could be identified and described. The PowerPoint slides were developed in accordance with the distance learning principles: texts were short, simple, easy to read; key points were highlighted; summary tables enabled the organisation of the knowledge; colours, frames and lettering were appropriately used, to produce a user-friendly educational material and enhance the learner’s interaction with it. For the blended learning, the course was uploaded to the educational platform of the Dental School, e-class. The educational platform (learning management system, LMS) is a software application used to design, implement and evaluate teaching and learning processes through online media. Web-based tools in university education include calendar, self-graded tests and quizzes, announcements, content up/downloading, online discussion groups, electronic submission of assignments, groups sign-up lists, access to external weblinks and email to from/students (7, 12). The following course materials were available in the online format:

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Course description – the course’s identity, including the aims and outcomes of the course, reading assignments l Announcements – notices posted for students on electronic bulletin board, maintained by the instructor l Agenda – the calendar of the course, including timetables, study organisation, dates for submitting the intermediate assessment tests, for the face-to-face meeting and the final test l Documents – the PowerPoint presentations and additional notes were uploaded, sequentially, according to the calendar l Quizzes – various self-assessment tests, including multiplechoice questions, right/wrong quizzes, radiographic images to diagnose; feedback was also provided l Links – to relevant websites and search engines l E-mail – unlimited access to instructor in an asynchronous mode The design of the educational methodology of the study was in line with the design proposed in other studies comparing the conventional to the online or blended teaching (17, 18) (Fig. 1). The students in the conventional group attended weekly lectures by the instructor, supported by PowerPoint presentations. During the same time, the students in the blended learning group studied online the same material and finally attended one face-to-face meeting with the instructor. The purpose of the face-to-face meeting was to summarise the educational content already studied by the students, highlight the key points and clarify any questionable or difficult issues. In addition, all students completed a number of tests and questionnaires, as follows: (a) before starting the course, both groups completed (i) a mandatory theoretical knowledge assessment test (pre-test) to identify their entry knowledge level, (ii) a computer knowledge questionnaire and (iii) a questionnaire of demographic information, expectations and attitudes; (b) during the implementation of the course, both groups completed intermediate knowledge tests, which were submitted online by the blended group students and in the classroom, at the end of the lectures, by the conventional group students; (c) at the end of the course, both groups completed (i) a mandatory knowledge test (post-test), at a face-to-face meeting, scheduled for that purpose and (ii) an evaluation-satisfaction questionnaire. Knowledge tests contained right/wrong, multiple-choice questions and radiographic images to interpret and document. Questionnaires consisted of dichotomal (yes/no), open-ended and five-point Likert-scale questions, where 1 represented a very negative response and 5 represented a very positive response. The questions aimed at eliciting students’ perceptions, expectations, attitudes and skills, communication and satisfaction related to the course design, delivery and outcome; questions l

were constructed by the authors and were consistent with those usually encountered in similar educational studies (8, 10, 12, 19–22). Only questions related to the educational effectiveness of the course and the students’ attitudes are discussed in the present study. Students’ attitudes towards blended learning were elicited from a number of questions in the pre-course questionnaire and also from questions in the post-course satisfaction questionnaire. A series of questions were answered only by the blended group students; six of these questions, the same, were posed to the students before and after their participation in the course, to assess whether their attitudes have changed after their experience. Statistics were obtained with Student’s t-test and Mann–Whitney U test (in case of small sample), using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). The level of statistical significance was set at P < 0.05.

Results The students participating in this study were 47, of whom 23 students attended the conventional teaching and 24 students the blended teaching. The profile of the students is shown in Table 1. The mean grades of the students at the knowledge pre-test and post-test are shown in Table 2. All students’ grades are illustrated in Fig. 2. We notice an increase in their grades after the implementation of the course and a difference between the two groups which was analysed by the student’s t-test (Table 3). A statistically significant difference was found (P = 0.005) between the post-test grades of the two groups (conventional mean 6.86 – blended mean 8.08). The mean post-test grades were also correlated to certain profile variables (gender, lecture attendance, average grades, computer ownership and self-assessment grade for computer knowledge), and no statistically significant difference was found. Next, we analysed the post-test grades of the female students, using the non-parametric Mann–Whitney U Test, and we found a statistically significant difference between the female students of the conventional and the blended group (blended 8.39 – conventional 6.96, P = 0.003). Similarly, a statistically significant difference was found within the blended group, between male and female students (male 7.34 – female 8.39, P = 0.04). Mean grades classified by gender and teaching method are shown in Table 4. The answers to the Likert-scale questions of the post-course satisfaction questionnaire related to the course efficiency are demonstrated in Table 5. Negative answers (1, 2) did not exist, apart from three students in the blended group (12.5%), who rated the study timetable as ‘barely enabling’ or ‘not at all enabling’. Almost all means ranged between 4 (enough positive) and 5 (very positive) of the scale, except for two means in

1. Conventional group Pre-test

Conventional learning phase

Evaluation questionnaire

Post-test

2. Blended group Pre-test

E-learning phase

Face-to-face meeting

Post-test

Evaluation questionnaire

Fig. 1. The design of the educational methodology. ª 2011 John Wiley & Sons A/S

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TABLE 1. Students’ profile

Gender Attendance of optional lectures Mean Mean Mean Other

average grade free time per day (h) working time in dental school occupations (hobby/job)

Volunteer activities Computer owner Mean self-assessment grade (1—10) Email address

Conventional group N (%)

Blended group N (%)

Male: 7 (30.4) Female: 16 (69.6) Yes 5 (21.7) 6.3 3.239 7.239 Yes 17 (73.9) Yes 9 (39.1) Yes 14 (60.9) 3.27 Yes 8 (34.8)

Male: 7 (29.2) Female: 17 (70.8) Yes 10 (41.7) 6.6 2.688 7.625 Yes 20 (83.3) Yes 11 (45.8) Yes 23 (95.8) 6.21 Yes 20 (83.3)

No 18 (78.3)

No 6 (26.1) No 14 (60.9) No 9 (39.1) No 15 (65.2)

No 14 (58.3)

No 4 (16.7) No 13 (54.2) No 1 (4.2) No 4 (16.7)

TABLE 2. Mean grades of the students at the knowledge tests Descriptive statistics

Knowledge pre-test Knowledge post-test

Teaching method

N

Mean

Std deviation

Std error mean

Conventional Blended Conventional Blended

23 24 221 24

5.8304 6.3583 6.8636 8.0875

1.5830 1.2176 1.3903 1.3820

0.3301 0.2485 0.2964 0.2821

1

One student in the conventional group did not perform the post-test. N, number of students. Grade scale: from 1 = minimum grade to 10 = maximum.

A

Conventional group

10

8

8

6

6

4

Fig. 2. Students’ pre-test and post-test grades (on a continuous scale from 1 = minimum grade to 10 = maximum grade).

B

10

Blended group

4 Knowledge pre-test Post-test

2

2

Knowledge pre-test Post-test

0

0 1

3

5

7

9

the blended group, concerning the study timetable and the selfassessment tests, which were close to 3 (moderately). Course organisation was rated as very satisfactory by 60.9% of the students in the conventional group (mean 4.61) and 66.7% of the students in the blended group (mean 4.67). The educational material was evaluated as ‘very’ and ‘enough satisfactory’ by 100% of the blended group students and similarly were evaluated by the same student group the online course design and the clarity of instructions. In the conventional group, course content and educational material were evaluated as ‘very’ and ‘enough satisfactory’ by a large percentage of students (approx. 95% and 91%, respectively). t-Test revealed no statistically significant differences between the two groups.

11 13 15 17 19 21 23 Students

1

3

5

7

9

11 13 15 17 19 21 23 Students

Table 6 demonstrates the answers to the questions related to blended group students’ attitudes, pre- and post-course. Concerning the elements of effectiveness and motivation, students have not changed their attitudes greatly after participating in the course: 90.9% believed that blended learning is more effective than conventional before the course and 87.5% believed the same after the course; 90.9% and 91.7% (before – after) believed that blended learning motivates students more than conventional. But 75% of the students thought that blended learning is more demanding than conventional, after the course, whereas 59.1% thought the same, before taking the course. No statistically significant differences were detected between the ‘before – after’ answers.


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TABLE 3. t-Test to assess differences between the two knowledge tests Independent samples test t-Test for equality of means 95% Confidence interval of the difference

Knowledge pre-test Equal variances assumed Equal variances not assumed Knowledge post-test1 Equal variances assumed Equal variances not assumed 1

t

df

Sig. (2-tailed)

Mean difference

Std error difference

Lower

Upper

)1.285 )1.278

45 41.315

0.205 0.209

)0.5279 )0.5279

0.4109 0.4132

)1.3555 )1.3622

0.2997 0.3064

)2.992 )2.991

44 43.606

0.005 0.005

)1.2239 )1.2239

0.4091 0.4092

)2.0483 )2.0487

)0.3994 )0.3990

One student in the conventional group did not perform the post-test. Bold denotes the statistically significant levels.

TABLE 4. Mean grades of the students at the knowledge post-test Descriptive statistics

Male Female

Teaching method

N

Mean

Std deviation

Min—max

Conventional Blended Conventional Blended

7 7 151 17

6.6429 7.3429 6.9667 8.3941

1.3138 0.9235 1.4573 1.4432

5.50—9.00 6.30—8.80 4.50—9.00 5.00—10.00

1

One female student in the conventional group did not perform the post-test. N, number of students. Grade scale: from 1 = minimum grade to 10 = maximum.

TABLE 5. Post-course satisfaction questionnaire Conventional group N (%)

Course content Course organisation Educational material Easiness to understand Comprehensive coverage of the subject Online course design Clarity of instructions Motivating study timetable1 Self-assessment tests2

Blended group N (%)

3

4

5

Mean (SD)

3

4

5

Mean (SD)

1 (4.3)

9 (39.1) 9 (39.1) 8 (34.8) 11(47.8) 9 (39.1)

13 (56.5) 14 (60.9) 13 (56.5) 7 (30.4) 10 (43.5)

4.52 4.61 4.48 4.09 4.26

1 (4.2)

10 (41.7) 8 (33.3) 9 (37.5) 13 (54.2) 15 (62.5) 13 (54.2) 6 (25) 13 (54.2) 9 (37.5)

13(54.2) 16 (66.7) 15 (62.5) 7 (29.2) 8 (33.3) 11 (45.8) 18 (75) 2 (8.3) 8 (33.3)

4.50 4.67 4.63 4.13 4.29 4.46 4.75 3.54 3.54

2 (8.7) 5 (21.7) 4 (17.4)

(0.593) (0.499) (0.665) (0.733) (0.752)

4 (16.7) 1 (4.2)

6 (25) 3 (12.5)

(0.59) (0.482) (0.495) (0.680) (0.550) (0.509) (0.442) (0.932) (1.744)

1

Three students (12.5%) answered 1–2. Four students (16.7%) did not perform any test. Likert scale: from 1 = very negative opinion to 5 = very positive opinion.

2

In general, blended learning is considered more advantageous than conventional for teaching theoretical subjects by 41.7% (‘very’ advantageous) and 45.8% (‘enough’ advantageous) of the blended group students (mean 4.21). One-third of the students assessed the face-to-face meeting as ‘very helpful’ for answering their queries and summarising the content and more than half (58.3%) assessed it as ‘enough helpful’ (mean 4.25) (Table 7).

Considering the overall opinion on the course, both groups had a positive opinion (means 4.43 for the conventional and 4.46 for the blended group) (Table 8). Blended group students were more positive, because all their answers were ‘very’ and ‘enough’ positive. No statistically significant differences were found between groups, neither between genders. Within the conventional group, female students had a statistically signifiª 2011 John Wiley & Sons A/S

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TABLE 6. Students’ attitudes pre- and post-course (Blended group) Compared to conventional teaching, I think that blended learning:…

…is more effective

…is more demanding

…is more motivating

…promotes active engagement

…promotes selfstudy and selfassessment

…enhances critical thinking

N (%)

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Yes No

20 (90.9) 2 (9.1)

21(87.5) 3 (12.5)

13(59.1) 9 (40.9)

18 (75) 6 (25)

20(90.9) 2 (9.1)

22(91.7) 2 (8.3)

22 (100)

21(87.5) 3 (12.5)

20(90.9) 2 (9.1)

23(95.8) 1 (4.2)

21 (95.5) 1 (4.5)

20 (83.3) 3 (12.5)

N, number of students.

TABLE 7. Students’ attitudes (Blended group) N (%)

1

Blended learning is more advantageous than conventional Face-to-face meeting was helpful

2

3

4

5

Mean (SD)

2 (8.3)

1 (4.1) 2 (8.3)

11 (45.8) 4 (58.3)

10 (41.7) 8 (33.3)

4.21 (0.884) 4.25 (0.608)

N, number of students. Likert scale: from 1 = very negative opinion to 5 = very positive opinion.

TABLE 8. Students’ attitudes (Both groups) What is your overall opinion on the course? N (%)

1

Conventional Blended

2

3 2 (8.7)

4 9 (39.1) 13 (54.2)

5 12 (52.2) 11 (45.8)

Mean (SD) 4.43 (0.662) 4.46 (0.509)

N, number of students. Likert scale: from 1 = very negative opinion to 5 = very positive opinion.

cant more positive opinion than the male students (male mean 4.00 – female mean 4.63 – P = 0.02). Two open-ended questions, intended for both groups, were ‘what did you like most in the course?’ and ‘what did you like least?’ Students in the conventional group liked the educational material (notes and PowerPoint slides) and the organisation of the content (classification, comparative tables, easy-to-read texts, summaries). One student stated, ‘the PowerPoint slides made me want to read them!’. Students in the blended group, in addition to the above, liked the combination of electronic and face-to-face teaching, the freedom of place and time, the e-studying and e-evaluation, the independence and individual effort. A student said, ‘I wish more subjects were taught this way!’. Students in both groups did not like the time and day of the face-to-face meetings (Friday afternoon), as they were very tired and could not concentrate on the subject and the fact that they had to study an extensive amount of information within a limited period of time. Blended group students also complained about the printing quality of the radiographic images, when they printed them from the online version.

Discussion The subject of the course ‘Differential diagnosis of mixed bone lesions’ is considered to be one of the most challenging subjects in oral radiology. Students must be able to identify the lesion

in the patient’s radiograph, describe its appearance and develop a justified list of possible diagnoses, based on (a) lesion’s location, size, shape, radio-opacity, (b) patient’s medical and dental history, age, gender and (c) the underlying histological and clinical image. This selection procedure demands a deep approach to learning, as it requires from the students to use their judgement capabilities and critical thinking to thoughtfully combine their knowledge from other disciplines (oral pathology, anatomy, radio-anatomy, histology, diagnostics and patient history) and create the diagnoses list. The blended methodology, where students – through the online education – become self-directed and capable of managing their own knowledge, is considered to enhance more than the conventional methodology students’ personal learning skills (judgement, decision making, reflective learning), thus leading to personalised, engaging, active learning. When implemented, blended and online courses are evaluated to determine both the effectiveness of the instruction and the student preferences and perceptions regarding the use of technology to support their learning. The process of evaluation is an integral element of all educational reforms and ensures the success of the course. Educational effectiveness is determined by using various parameters, such as, student performance, student satisfaction, attitudes and skills, the accomplishment of course goals and objectives, the teachers’ perceptions and evaluation of the course (5, 7, 12, 19, 23). In the present study, we estimated the educational effectiveness through (i) the students’ performance at the knowledge tests, which is derived from their grades and (ii) the efficiency of the course, derived from the relevant questions of the questionnaires, a methodology followed in similar studies (19, 24). As far as students’ performance is concerned, we found that a statistically significant difference existed whilst comparing the mean grades of the post-knowledge test, indicating that the students of the blended learning group performed significantly better at the end of the course than the students of the conventional group. Such results, showing better student performances


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at the online-enhanced courses, have recently appeared in the educational literature (25, 26). Dziuban et al. (27), in their study comparing blended courses with fully online and face-toface courses, reported that the blended model was comparable to or – in some cases – better than face-to-face, as far as the student grades were concerned. A significant difference between the male and female students of the blended group (male 7.34 – female 8.39) was also found, concerning the mean grades of the post-knowledge test, indicating that the female students performed significantly better than their male colleagues of the blended group. This result could be explained by the gender personality differences: female students are generally considered to be more focused on their studies, more dedicated and hardworking than their male colleagues. Another interesting result was that the female students of the blended group (mean grade 8.39) performed significantly better at the post-knowledge test than the female students of the conventional group (mean grade 6.96), a result that generates the overall statistical difference between the two groups, as discussed before. It seems that female students perform better with the blended methodology, which can be attributed to a combination of the two factors involved: the gender characteristics and the educational methodology. The efficiency of the course was at a high level, based on students’ answers to the relevant questions. Particularly, students from both groups appreciated very much the organisation of the course and content, and the educational material. This can be explained because (i) the organisation followed the distance learning and student-centred principles and (ii) the material was original, developed especially for this course and it did not resemble any existing written or electronic material. Although the material was developed according to the distance learning principles (independent learning, interaction, clarity, friendliness and motivation), it was highly evaluated by the conventional environment also. The quality of e-learning material and the students’ evaluation are important factors in determining the success of web-based courses in higher education, and dentistry in particular. These parameters were also used in the study of Tan et al. (28), in which a traditional dental radiology course has been converted into an e-learning course and the results indicated – based on students’ positive response and the quality of the content – that the e-learning version could be fully implemented. Similar approaches were used in evaluating an online orthodontic learning resource (8) and an interactive online module on removable partial dentures (13). It came as a surprise to us the very positive comments of the students on the PowerPoint slides, particularly as expressed in the open-ended questions. PowerPoint presentations are simple e-learning media, including minimal animation, colouring and interaction possibilities, yet still appreciated by the students. This is in accordance with the study of Olapiriyakul and Scher (5), where 78% of the students evaluated the PowerPoint presentations as ‘useful, concise and clear’, stating that they were ‘an effective instructional method’, whereas, at the same time, they evaluated low the narrated PowerPoint slideshows, failing to see the usefulness of the additional narration.

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The study timetable and the self-assessment tests, two features that promote the self-study and self-evaluation, were moderately rated by the blended group students. As it has been concluded, non-mandatory online tests and self-assessment activities are likely to improve students’ motivation and enhance learning experiences (19, 20). In the present study, students failed to recognise the importance of the self-assessment tests and the feedback they provided in their learning process. Dental students are used to a traditional teaching methodology; thus, it seems difficult for them to become active, self-regulated learners. Another reason could be the poor design of these elements by the instructor, ending in non-motivating activities. Conventional teachers must learn the necessary technological skills, pedagogical principles and teaching strategies to create effective educational online environments. Students must relearn how to learn and teachers must relearn how to teach (27). Students’ attitudes towards certain components of blended learning have changed after participating in the course (but not statistically significantly). Students stated that blended learning proved to be more demanding, compared to conventional, than they initially thought, and this finding has been reported in another study, where students felt that the hybrid class was much more work than the conventional one (23). It is not unusual for students – and even teachers – to perceive e-learning as an easy methodology with minimal obligations, requirements and involvement. After participating in an e-course, they realise the necessity for active engagement, self-discipline and effective time management. The face-to-face meeting was highly evaluated by most of the students. Students still like the visible communication with the teacher and the social interaction with their colleagues. Previous studies report that students generally have a positive response to web-based instructional formats, but that classroom interaction and participation are still seen as a necessary component to education (17). Students prefer that online modules are used as a support to learning (10), and they dislike the replacement of traditional lectures by the online format (8). In the open-ended questions, students in both groups did not like the time and day of the face-to-face meetings (Friday afternoon), as they were tired and could not concentrate on the subject. The timing of the classes as a negative issue (08:00 h) has been noted before (10). Also, students stated that the amount of information was too extensive, but this concept is probably attributable to the high difficulty of the subject rather than to the extent of it. Blended group students complained about the printing quality of the radiographic images, when they printed them from the online version, which is true, as the resolution and size of online images is very low, to produce quickly downloadable files. But, the image quality, as expressed by its contrast and resolution, is of major importance in a subject like dental radiology, where a diagnosis has to be made from these images. The ideal would be that all students would read the material on the computer screen, where imaging is adequate; printing is a choice that, apart from deteriorating the quality, is also environmental unfriendly. This remark highlights the issue of reading extensive educational material on the computer screen, which is neither preferable nor easy for the students (29, 30). ª 2011 John Wiley & Sons A/S

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Conclusions A blended methodology for teaching dental radiology to undergraduate students has been evaluated in the present study, and the findings support the introduction of blended learning to the undergraduate dental curriculum. Concerning student performance, students in the blended group performed significantly better in the knowledge post-test than their colleagues in the conventional group. Students also evaluated the course components in a positive way: the content, organisation, educational material and design were highly appreciated by students in both groups. Students’ attitudes towards blended courses were positive: they think that blended learning is effective and motivating; it promotes active engagement and enhances self-study and self-assessment. Particularly, students in the blended group liked the combination of electronic and face-to-face teaching, the independent studying and the availability of the online material at any time. Although the overall opinion of the students concerning the course was very positive, certain elements of the course were not as successful as others: the self-assessment tests and the study timetable were not considered useful or motivating by the students.

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