The development of a serious game for laser applications in dentistry and the evaluation of dental students' satisfaction

Background This study aimed to design and implement a gamified application about the theoretical aspects of laser applications in dentistry and investigate students' satisfaction with their learning experience. Methods An engaging educational program named Essential Skills and Knowledge in Learning Laser (ESKILLD) was developed to teach laser applications in dentistry. The program comprises two primary components: a “Tutorial and Quiz” section and a “Games” section. Final-year dental students were tasked with installing and using this application. A 29-item validated questionnaire (Cronbach's alpha = 0.97, ICC = 0.94) was used to evaluate students' perceptions of the applications' design and functionality. The influence of participants' gender and Grade Point Average (GPA) on their satisfaction levels was examined via the student t-test and Pearson's correlation, with a significance level of 0.05. Results The study had 56 participants, of which 37 were female (66.07%), and 19 were male (33.92%). The students' average GPA was 15.16 out of 20. The mean rating for ESKILLD's design and functionality was 1.39 ± 0.47 and 1.37 ± 0.46, respectively, signifying a high satisfaction level. Female students rated the application's coherence and learning perception significantly higher than their male counterparts (p < 0.05). However, gender did not significantly influence scores on other perception aspects or overall scores. Students' GPAs and their perception scores did not have a significant correlation. Conclusions The results indicate that the participants were generally satisfied with the game's features and attitudes towards it, which underscores the potential effectiveness of gamification in dental courses focused on laser applications.


Introduction
Laser technology has been introduced into the dental field to shorten treatment times, increase treatment efficiency and effectiveness, and improve patient comfort.It has been demonstrated that lasers can improve wound healing and reduce postoperative complications, blood loss, and trauma at the surgical site [1].Lasers can be used for incision, ablation, tissue healing, the removal of hyperplastic tissue, and photodynamic therapy [2].Due to the growing popularity of laser dentistry, it is necessary to educate dental students about this subject properly.
In Iran, traditional dental education includes didactic courses, preclinical lab training, and clinical patient experiences, similar to other countries.Over the last two decades, advances in educational approaches have provided new methods to explore and improve students' performance.Technological advancements and the widespread use of digital devices have allowed the incorporation of E-learning into educational systems [3].Smartphonebased mobile learning has a comparable, and even slightly superior, efficacy to lecture-based learning [4].
Gamification incorporates game elements into nongame contexts to increase student motivation and engagement [5].Game-based learning has a pedagogical purpose [6].In dentistry, the use of online gamification platforms, such as Kahoot!® , has resulted in increased satisfaction among dental students in the teaching of microbiology, immunology, and histology concepts [3,7].Game-based learning has been effective for various subjects in dentistry, including oral histology [6], orthodontics [8], learning orofacial spaces [9], oral lesions diagnosis and treatment planning [10], endodontics [11], oral rehabilitation of edentulous patients [12], clinical communication [13], teledentistry training [14], basic life support skills [15], and clinical reasoning skills [16], has shown a positive effect on students' motivation, selfperceived confidence, awareness, self-efficacy in learning, cognitive skills, knowledge.Digital gamification platforms engage students with different learning styles due to their easy accessibility and ability to integrate well with varied teaching methods while significantly increasing student participation and engagement in the classroom compared to traditional lecture-based teaching [17].Furthermore, gamification can enhance the learning experience and course satisfaction by providing joy and excitement through educational games, self-assessment, and rapid feedback [3].
The satisfaction of students with their learning experience is linked to improved mental and physical health as well as academic success [18].Due to the benefits of game-based learning, the current study investigated dental students' satisfaction with a newly developed gamified mobile application as an adjunctive method in educating laser applications in dentistry.Additionally, the study examined the relationship between students' satisfaction and their demographic characteristics to determine if the game could be beneficial for students with different genders and educational backgrounds.

Setting and population
The present cross-sectional study was conducted at the Mashhad University of Medical Sciences Dental School from September 2021 to June 2022.The study was conducted in two phases: designing the game and evaluating students' satisfaction with the application feathers and their learning experience.
The school curriculum for Laser Applications in Dentistry includes one theoretical and one practical course for 6th-year students, namely Laser in Dentistry and Clinical Applications of Laser in Dentistry, respectively.The students who were taking the courses during the study voluntarily participated in the study through total population sampling.

Game design
An educational and entertaining application for laser application in dentistry was designed and created for the Android operating system.The application was named ESKILLD, a synonym for Essential Skills and Knowledge in Learning Laser.The initial development of the application was based on focus group interviews conducted with a group of three undergraduate students, a post-graduate student (M.K.), a professor of Oral and Maxillofacial Diseases (J.S.), a professor of Community Oral Health (A.K.), a professor of Community Medicine and Public Health (M.KR.), and a software developer and media designer.The topics investigated in the focus group were framework conditions, gamification aspects, digital platforms, and possible applications.The instructor (J.S.) translated the content into English, and certified translators translated it into French and Italian.The final version of the application was developed using Ktor, an open-source framework for the Kotlin programming language, which is available for Android operating systems.The entire development process took approximately three months with an estimated cost of $560.
Learners first needed to registrar in the application and choose their preferred language from Persian, English, French, and Italian (Fig. 1).After selecting the language, students were provided the option to select "Tutorial and Quiz" or "Games" (Fig. 1): A Tutorial and Quiz (Fig. 2): The user is guided through six objectives in this part, following a "road map." These objectives correspond to the Laser in Dentistry course curriculum and include: 1) Fundamentals of Laser Physics, 2) Laser Absorption Spectrometry, 3) Laser-Tissue Interactions, 4) Laser Safety, 5) General Applications of Lasers in Dentistry, and 6) Unique Applications of Lasers in Dentistry.Each objective contained short educational videos with subtitles recorded by the instructor (J.S.).The video's duration ranged from 6 to 20 min.Several questions from the subjects followed the videos.Several questions from the subjects followed the videos.According to the feedback system within the game, learners could receive immediate responses.B Games (Fig. 3): When participants chose the "Games" section, they could opt for a "Drag-anddrop game" to learn about laser safety or a "Similarity game" to assess students' understanding of different types of lasers and their clinical applications by selecting related pictures.
The application's domain (www.eskil ld.ir) had a panel manager.The instructor could register on the panel manager and monitor students' performance regarding time spent on the application and correct and incorrect answers to the questions.

Students' satisfaction
The satisfaction of the participants with their learning experience was evaluated using a researcher-made online questionnaire consisting of 29 items adapted from previous literature.The questionnaire was prepared to reflect the games' design and performance with nine perceptions: Presentation, Attraction, Coherency, Esthetic and Consistency, Visual Aspects of Pictures, Text and Content, Technology and Multimedia Support, Educational Aspects of the Content, Attitude, and Learning.
The content validity of the questionnaire was determined using the Content Validity Index (CVI) and Content Validity Ratio (CVR) [19].A group of 10 experts specializing in Oral and Maxillofacial Diseases individually assessed each questionnaire item for relevance and clarity.Experts rated the relevance of each item on a scale from 1 (not relevant) to 4 (highly relevant) and the essentiality of each item on a scale from 1 (essential) to 3 (not essential).The CVR was calculated using the formula: Fig. 1 After registration, learners chose their preferred language from Persian, English, French, and Italian.Then, they selected "Tutorial and Quiz" or "Games" Ne represents the number of experts rated the item as "Essential, " and N is the total number of experts.
The CVI was calculated by dividing the number of experts who rated each item as either 3 or 4 in terms of relevance by the total number of experts.In this study, the CVR and CVI values were 0.64 and 0.80, respectively, indicating satisfactory content validity.
The questionnaire's internal consistency was assessed using Cronbach's alpha coefficient.Data from 20 dental students resulted in a Cronbach's alpha value of 0.97, indicating excellent internal consistency among the questionnaire items.
Test-retest reliability was evaluated by administering the questionnaire to a subgroup of 20 dental students on two occasions, two weeks apart.Analysis using the Intraclass Correlation Coefficient (ICC) showed strong agreement between the two administrations, with an ICC value of 0.94, demonstrating the high stability of the questionnaire over time.
The instructor, J.S., conducted a 30-min in-person demonstration of the application in the Laser department.
Students were asked to install the application on their cell phones and use it along with the course and traditional lectures.Six students did not have access to an Android operating system.Following the in-person demonstration, they were given a cell phone with an Android operating system to try out the application in that session, and they were allowed to go to the Laser department and use the application whenever they wanted to.
Participants were asked to rank the satisfaction survey questions according to a 5-point Likert-type scale ("Strongly agree = 2," "Agree = 1," "Neither agree nor disagree = 0," "Disagree = -1," "Strongly disagree = -2").The final scores were interpreted as follows: 1 to 2 for excellent, 0 to 1 for good, 0 to -1 for poor, and -1 to -2 for very poor.Additionally, demographic data including participants' gender and the grade point average (GPA) from their preceding five years of education were recorded.

Statistical analysis
Data analysis was conducted using SPSS software version 23 (IBM, NY, US).To evaluate the association of participants' gender with their satisfaction level was evaluated using the student t-test.Participants' GPA correlation Fig. 2 When the students selected "Tutorial and Quiz, " they were guided through the objectives on a "road map." Then, they selected the subject, watched the tutorial, and answered the questions about that subject with their satisfaction level were evaluated by Pearson's correlation (α = 0.05).

Ethical considerations
The protocol of the present study was approved by the Research and Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.DENTISTRY.REC.1400.031).Participants had the right to withdraw from the study whenever they desired.Assurance was given that their identity would remain confidential and the study results would be published anonymously.
Table 2 represents the difference between the questionnaire scores among genders and the correlation between the students' GPA and their satisfaction scores.The mean scores of female students were comparable regarding most of the presentations.However, female students rated Coherency (p = 0.019) and Learning perceptions significantly higher than male students.The Pearson correlation coefficient (r) between the participants' GPA and Design-related presentations, Performance-related perceptions, and Total Score were found to be 0.010, 0.05-, and 0.01-, respectively.Despite the low correlation coefficients observed between GPA scores and each measure, none of the correlations were statistically significant.These findings suggest no significant linear relationship between the students' GPA and satisfaction scores.

Discussion
The findings of this pilot study revealed that last-year dental students at Mashhad Dental School positively evaluated the design and performance of ESKILLD.Students' gender and GPA did not affect their learning experience satisfaction level using ESKILLD.
Student satisfaction with the game's features and content may enhance learning through repetition, increasing motivation, and identifying complex concepts [3].In several studies, students have reported that gamification enhances their interest in the course subject, knowledge acquisition, and retention, emphasizing the most critical aspect of the lesson for review [20].Similar to the current study, high levels of user satisfaction and perception were reported in other studies using game-based learning for learning orofacial spaces [9], oral histology [6], factual knowledge [21], and clinical communication [13].Tantawi et al. [22] reported that gamification significantly improved dental students' academic writing scores; however, their writing satisfaction and self-perceived improvement were modest.In their study, students' participation in academic writing was mandatory and might have affected their satisfaction.In contrast, participation in our study was voluntary.Despite the impossibility of comparing the studies due to the dissimilarity of the subjects and game designs, the participation condition may affect students' learning experience.
In a recent qualitative study, researchers investigated the most critical game elements from the perspective of medical students.The top three key elements identified were integration with instructional objectives, game rules, and rapid feedback [23].In ESKILLD, educational videos were included, aligning with conventional theoretical laser course objectives and the instructional objectives.In addition, students answered various questions and played games related to the subject, which aimed to enhance information retrieval, strengthen information retention, and help them identify their weaknesses, something that is not feasible in a traditional learning environment [24].Therefore, ESKILLD allows for both synchronous and asynchronous learning [25].Students received immediate feedback on their correct or incorrect answers, which enabled them to estimate and track their progress [25].Thus, the high user satisfaction with ESKILLD may be attributed to the incorporation of key gamification elements in the application's design.However, conducting a trial with a control group was not feasible due to the potential for the application being shared among the test subjects.Moreover, ESKILLD was utilized as a supplementary tool during the instructor's lecture.The study did not evaluate cognitive improvement.Furthermore, ESKILLD and the instructor's lecture were used as supplementary tools.As a result, it was not possible to assess the impact of ESKILLD on enhancing students' knowledge, especially in the absence of a control group.
Several studies have employed online gamification platforms (such as Kahoot! and Quizizz) as a learning tool.These platforms, which may or may not be teacheroriented, are believed to improve learning by providing multiple-choice questions.In dentistry, Felszegly et al. [7] found that Kahoot!courses on medical and dental histology increased participant satisfaction.Nguyen et al. [3] found that using Kahoot! to learn microbiology and immunology improved dental students' attitudes towards the course, as well as their perceptions of their Table 2 The relationship between presentations' mean score and participants' gender * Significant difference between genders based on the result of student's t-test (p < 0.05) a The questions were ranked as follow: "Strongly agree = 2," "Agree = 1," "Neither agree nor disagree = 0," "Disagree = -1," "Strongly disagree = -2" comprehension and retention of key concepts.Similarly, ESKILLD utilized multiple-choice questions, with 89.3% of participants reporting that gamification significantly enhanced their learning of laser information and applications.Nonetheless, while Kahoot! has a teacher-oriented design, ESKILLD can be used as a supplement to asynchronized material and contains other games.

Presentation
There have been assessments of dental students' and practitioners' knowledge of laser applications in dentistry.According to a study conducted in Saudi Arabia, 76% of fourth-year dental students lacked adequate laser application knowledge [26].In another investigation, most final-year dental students in Iran favored adding laser courses to the curriculum [27].Dental clinicians also showed insufficient knowledge of laser application in dentistry [28,29].Sarabadani et al. [30] reported that using the mobile educational application Moodle to teach laser application in dentistry significantly increased dental students' knowledge compared to using a booklet.Consequently, portable, evidence-based interactive programs for learning laser applications in dentistry may enhance dental practitioners' understanding of this critical subject.In the current study, most students positively rated the educational aspects of the content of ESKILLD.Students have also reported familiarity with the surgical procedure for treating oral lesions (85.7%), and clinicians can use the game to select the laser type and setting (87.7%).Therefore, ESKILLD may be a valuable tool for students and practitioners to acquire or refresh their knowledge of lasers in dentistry knowledge.In addition, the content has been translated from Persian to English, Italian, and French, and the user can select the language upon entering the application; thus, students and clinicians worldwide can benefit from using this game.
Numerous studies have compared the effectiveness of digital learning methods to traditional lectures.Goob et al. [31] compared the satisfaction of dental students with Zoom conferences, Livestream, and prerecorded PowerPoint to traditional lecture formats.According to their findings, students were more satisfied with asynchronous learning.The widespread acceptance of asynchronized education is primarily because one can view the content again at a convenient time and place [32,33].However, asynchronized education lacks interaction, collaboration, and social exchange [34].Therefore, numerous studies have concluded that combining traditional and digital instruction is the most effective method for achieving educational objectives and student satisfaction [35,36].Additionally, students may submit their questions via email.In the present study, ESKILLD was provided to students along with the conventional laser course, and students could consult with the professor regarding any questions.Due to the increasing popularity of digital education, however, additional research is required to compare the educational outcomes of using ESKILLD alone versus traditional lectures.
It is essential to take the gender variable into account when exploring learner attitudes and perceptions in serious games-assisted learning [37].Men tend to be more analytical, confident, solitary, and assertive when playing serious games [38].On the other hand, women tend to be collaborative, subjective, and reflective [38].In the current study, although female students reported a higher coherency in ESKILLD content and better learning, both genders were similarly satisfied regarding the design-related and performance-related presentations.Furthermore, we hypothesized that students' educational background could influence their learning experience.However, the current study participants' GPA of the preceding five years did not influence their satisfaction.Therefore, ESKILLD seems to be an appealing game for various groups of students.Similarly, Sipiyaruk et al. [39] found that dental students from the United Kingdom and Thailand showed similar knowledge improvements after using a serious game learning environment for dental public health.
The current investigation had some limitations.The findings may not be generalizable because the study only included students from one dental faculty.In addition, due to the lack of research on educational games, it was impossible to evaluate the effects of game components.Like most other studies on gamification, our research concentrated on students, while limited research has been conducted on instructors' and faculty members' perceptions.Additionally, the application was designed for the Android operating system, thereby confining its usability to individuals using alternative operating systems.In this study, we have tried to overcome this limitation by a presentation session and providing a device with an Android operating system in the Laser department.However, due to accessibility limitations, students with iOS cell phones may not have enough time to appraise the game thoroughly.Therefore, future versions will consider other operating systems in the application design.Moreover, designing a trial with a control group was not possible due to the possibility of sharing the application between the test subjects.Furthermore, using qualitative feedback from the students on their learning experience in future studies would also help reveal positive and negative aspects of ESKILLD and areas of improvement to work on.

Conclusion
In this study, ESKILLD, a new gamified laser application for dentistry, was developed.Sixth-year students reported high satisfaction with ESKILLD's design-related and performance-related presentations.The participants' positive attitude may reinforce the possibility of incorporating gamification in laser applications in dentistry courses.Furthermore, the GPA was not a significant factor in participants' satisfaction.Moreover, female and male students' satisfaction was comparable in most items and total scores.Therefore, ESKILLD may be appropriate for students from various educational backgrounds and genders.

Fig. 3
Fig.3After selecting "Games, " the students decided to play a "Drag-and-drop game" for laser safety or a "Similarity game" for selecting clinical applications related to different types of lasers

Table 1
Survey questions and mean score for each question and presentation