Exploring the Ways in which Generation-Z Dental Students Learn and How this Could Impact Dental Foundation Training

Short for Generation Z, ‘Gen-Z’ is a colloquial term used to describe anyone born between 1997 and 2012.¹ They are the first generation born into an integrated and globally connected world where the internet has always been available, and they have certain characteristics (Figure 1). Gen-Z makes up a large proportion of current dental students and, therefore, those now graduating and entering the world of work. Having spoken to current dentists and tutors at dental school, and with the COVID-19 pandemic being one of the major influencing factors, the way students learn, both at home and at university, has changed significantly over recent years. While many current dental practitioners would previously have relied on books and in-person lectures, there has been a large shift towards online learning and different styles of teaching, as well as the use of different resources for learning both theory and clinical practice. The implications of this difference in learning for dental students and dental foundation trainees should be addressed to ensure that all those in this new generation of dentists are both competent and confident in their practice.

Clinical learning

There are concerns that, with a technology-orientated lifestyle, those in Generation Z run the risk of losing the social skills learned through frequent face-to-face communication and interaction.^2,3 Hence, it could be said that the face-to-face clinical learning that exists now is as important as it has ever been. There are clinics in the dental hospital, and various clinical opportunities outside this setting. These include outreach placements in different practices, such as in the community, in regional hospitals shadowing specialists, and an elective where dentistry can be practised abroad. As a result, students gain a first-hand perspective of how vast and varied a career in dentistry can be, while building those essential communication and clinical skills.

In Sheffield, we are fortunate to have a haptic virtual reality suite at the dental school. It is a relatively new piece of technology, which is in keeping with our generation that has been raised in a digital world. Students begin using this during their first year. When it comes to learning operative dentistry, it acts as a good starting point for learning about optimal posture and how to hold instruments correctly. During the second and third years, students move onto practising cavity preparations. This, in combination with other teaching methods, gives plenty of opportunities to hone manual dexterity skills and understand the principles of operative dentistry.

In the early years of the course, students are introduced to learning clinical skills on ‘phantom heads’. Traditionally, the tutor would hold a demonstration on the day before sending students off to practise. The use of flipped learning videos, implemented at our dental school during the COVID-19 pandemic, transformed this method of teaching. Pre-recorded demonstration videos were accessed prior to the session, which ultimately changed how we learned new clinical skills. As a somewhat tech-savvy generation, this approach came as a natural progression for most. Students were then expected to attend with an understanding of what the session would entail, which meant that they were further adapting time management and organizational skills. Each video would also have a quiz to test knowledge of the subject, mirroring the literature, and suggesting that flipped learning encourages the development of critical thinking and problem-solving skills.⁴ Learning could be tailored to individuals, enabling students to take more responsibility for their learning and to feel more confident before the session.

The introduction of flipped learning allowed for an active and interactive way of engaging and motivating students so that they would arrive with questions, benefit from additional clinical time to practise and essentially have a more enjoyable session. Özcan⁴ showed that students taught restorative dentistry with the flipped classroom learning method achieved a 30.5% increased pass rate in their final exams compared to those taught with the traditional classroom.

This is not to say that flipped learning alone is appropriate for all clinical aspects of the course, as clinical dentistry can only be practised in person, and not being face to face with a teacher is shown to have a negative impact on overall student learning.⁴ For example, we enjoy developing in-person relationships with our tutors and engaging with peer review with our fellow students. Flipped learning does, however, add another dimension to teaching, and suits a collaborative learning style from which generation Z may benefit.⁴ When considering study days within DFT, this method could be used, at least in part, to provide consistency with dental school teaching, and encourage new methods of learning.

Social media

Following on from Generation Z's expectation of information to be available in seconds, the use of social media is something that could be argued is woven into the fabric of today's society. There is no doubt that social media plays a significant role in the lives of most Generation Z students. However, is social media useful for student learning, particularly in the field of dentistry?

On one hand, social media can be viewed as beneficial to student learning and may be used as a tool in dental education. Recent evidence has shown that the use of social media has the potential to facilitate improved learning and engagement across health professions and improved peer–peer communication in clinical education.⁵ YouTube is a particularly helpful educational resource, allowing dental students and dentists from across the world to access free tips and tutorials on almost any procedure or subject. We have found it to be a widely used tool that supplements learning in dental school, and is an easy and convenient way to watch videos of a procedure before performing it in a clinic. This style of visual learning has been shown to not only improve confidence, but educate students in a way that they may not have been exposed to before. Despite the new push for flipped learning videos, where specific clinical skills are concerned, there is the feeling that visual learning and videos are still limited in undergraduate dental education, therefore YouTube videos can be used by some students to ‘bridge the gap’.

On the other hand, potential problems and negative effects on learning may be associated with social media use, for example, with the creation of a negative digital footprint accessible for public view, and for aspects of clinical governance with the risk of privacy violations and breach of patient confidentiality when using social media.⁵ The use of YouTube also has the potential for students to learn the wrong techniques, develop bad habits, or learn differently from how their dental school teaches. It is also common for dental students to follow dental influencers on platforms such as Instagram, often for aesthetic restorations and procedures. This can favour a glamorized side of dentistry, where beautiful restorations are carried out in luxury private practices. However, many of these dental Instagram accounts arguably show unrealistic and unattainable standards for undergraduates and newly graduated professionals. The use of these online platforms brings the risk of making comparisons with day-to-day work, which can result in Generation Z dentists who follow these accounts feeling inadequate and losing confidence, particularly if working within the time constraints of NHS dentistry. Additionally, dental foundation trainees may be put under increased pressure to have aesthetically perfect work. Comparisons between the work of clinicians, unless for educational purposes, should be strongly discouraged to prevent confidence in one's abilities deteriorating. Overall, social media has the potential to progress dental education immensely, but it is not a replacement for the education at dental schools that is evidence-based, regulated by the General Dental Council and often led by experts.

Textbooks: traditional versus digital

In a time where the culture of Generation Z is one of consuming relevant information as quickly as possible, e-textbook technology makes for an effective learning experience for dental students. Generation Z requires information at speed, and ultimately, searching for an e-book online is faster than going to a library or book shop. Generation Z also advocates for efficiency, and if multiple textbooks are required, opening tabs on a computer is more efficient than a pile of textbooks on your desk. The need to buy multiple physical textbooks can also put a financial burden on students. Conversely, e-textbooks are often free online and can be saved and accessed from any location, improving accessibility for dental students. Sheffield University has provided a list of e-textbooks available and relevant for each theme throughout the course to aid learning.

Having said this, dental students still see the value in physical textbooks. When students opt for traditional sources, they tend to choose those with a more general outlook covering a range of topics. As the first generation to grow up with smartphones, having quick access to any information required, at all times, Generation Z see the value in a concise textbook, from a trusted source, containing ‘everything they need to know’. By having many textbooks available to loan from the library, it ensures those who prefer physical textbooks are catered for.

The shift towards an e-textbook preference is relatively recent. While Millennials, those born between 1981 and 1996, made up the dental student cohort, the transition between physical textbooks and e-textbooks began. When US, Puerto Rican and Canadian dental students were asked to express their opinions on physical versus electronic textbooks in 2012, the majority preferred traditional textbooks, and over 50% did not use the required e-textbooks at all.⁶ Similarly, when 50 dental students were surveyed in Chennai, India in 2016, 72% preferred traditional textbooks over e-textbooks.⁷

When having to choose between physical or digital textbooks, Generation Z would be more likely to choose digital. However, it may be debated that textbooks in general, whether physical or digital, are no longer the study medium of choice. Traditionally, one can envisage a student with a textbook, paper and pen in hand. Nowadays, online lectures and PowerPoints are a dental student's first source of information. When further information is needed, they may search for it online via dentistry blogs and videos, before looking at e-textbooks if they have still not found their answer.

Although from the present authors' experience, while textbooks have been used less compared to our predecessors, the value of textbooks is not forgotten. Being a source of carefully curated, evidence-based information, Generation Z dental students respect the reliability of information in textbooks and will use them when studying a topic in greater detail if other methods have not provided the level of detail they seek.

It is likely that online resources and textbooks will continue to grow in popularity, potentially replacing traditional textbooks in the future. Therefore, it is important that textbooks continue to digitalize their findings to facilitate the learning of dental students and dentists in their career progression.

Face-to-face versus pre-recorded online lectures

Traditional in-person lectures have been a vital component of dental learning at universities for decades, and, over this time, their method of delivery had changed very little. Before the pandemic, lectures were normally delivered face to face, and often recorded for later use as revision resources. Sheffield University emphasized the importance of physically attending these lectures, and the availability of lecture recordings and pre-recorded online content was not regarded as an adequate substitute. However, after experiencing an extended period where face-to-face teaching was not possible, a shift towards the use of online pre-recorded lectures, in combination with in-person lectures, has been seen.

The present authors have found that this combined approach works well at our university. Time previously spent in lecture theatres can now be spent on clinics and learning from pre-recorded content at our own pace. We have found the ability to pause, rewind and rewatch lectures invaluable in preparing for exams and for understanding the content.

A 2016 study investigated the impact of using voice-over, screen-captured presentations for undergraduate dental students, finding that this method of teaching, compared with face-to-face lectures, did not affect students' learning outcomes.⁸ However, when longer-term learning was considered, online lectures ‘had more of a positive impact’ and led to better long-term recall and recognition of information.⁸ Despite the positive impacts of recorded lectures, we have found that online learning requires more self-discipline because it lacks the structure of timetabled face-to-face teaching, and attendance is not recorded, contrasting with monitored and compulsory in-person teaching.

The social aspect of having face-to-face lectures is an underappreciated, but important consideration, particularly in the early years of dental school, before spending time on clinics. Lectures are generally the place where a cohort of students get to know each other, and where help can be given. Therefore, we think a combined approach is likely to continue at many dental schools.

Pre-recorded and online content also seems to have been integrated into postgraduate learning, as many talks and presentations are now delivered in this way. This is ideal for both new and more experienced dentists. It allows them to develop their knowledge and skills from the comfort of their own homes at times that suit them. Not having to attend in person reduces travel and its associated environmental impact. This has also significantly improved access to global learning and the sharing of knowledge because many teaching resources are now available across the internet to dental professionals and undergraduates alike.

Sustainability

Sustainability in healthcare is an increasingly relevant conversation, and one that may be lacking in some dental settings. Healthcare accounts for approximately 4–6% of global CO₂ emissions, a figure that is rising.⁹ While universities are generally strong advocates for sustainability, in the present authors' experience, there are limits to sustainable practice in clinical settings because of NHS constraints. This is evident in the reliance on single-use plastics, lack of recycling facilities and the gratuitous waste of materials.

However, this is beginning to change as some dental schools in the UK are working to integrate sustainability into their curriculum, and we are optimistic that sustainability considerations will begin to impact the operation of dental hospitals. In our own dental school, we have seen a significant increase in willingness to shift to more sustainable practices, reflected by the creation of our school's Sustainability Committee, and active research groups looking at ways to be more sustainable.

A 2021 study found that 59% of 16–25-year-olds were very, or extremely, worried about climate change,¹⁰ therefore, sustainability is of particular interest to Generation Z dental graduates. This creates opportunities for foundation dentists to work together with their colleagues to integrate more sustainable practices into their work. Incorporating sustainability into BDS curricula will also equip new graduates with a basis of knowledge and skills that they can employ in GDPs and hospitals.

Decolonizing the curriculum

While Generation Z is considered a dynamic and rapidly evolving demographic force that advocates for growing inclusivity, equality and diversity, the impact of racial disparities on the educational experiences of Black and minority ethnic students continues to be a significantly under-represented topic in UK healthcare education. With campaigning among students and staff in higher education for ‘decolonization of the curriculum’ to increase inclusivity and representation, improving the educational experience for dental students would help to address inequalities in healthcare provision for minority ethnic patients.¹¹

The link between ethnicity and disease has particular importance. Ethnic origin and skin colour of patients can have a remarkable impact on the prevalence and clinical presentation of disease, which can affect the diagnosis and subsequent treatment provision by dental professionals. The classic signs and symptoms of oral and medical conditions may prove difficult to identify in minority ethnic individuals if the teaching predominantly relates to White patients, which may impact adversely on timely management of individuals who do not seem to adhere to the ‘perceived norm’.¹¹ It is noted that many oral and dental conditions present quite differently and are often less pronounced in patients with darker skin. Without appropriate training, dental foundation trainees may miss or struggle to detect these signs efficiently in Black and South Asian patients, especially during medical emergencies.

Dental schools in the UK must continue to actively pursue decolonization of dental curricula. The topic should be addressed by all in the profession because it is instrumental in reforming educational outcomes and patient care.¹¹ Our dental school is currently implementing changes and creating resources to help address this issue.

Conclusion

In an age of greater inclusivity, changing educational attitudes and increased focus on our planet, the profession of dentistry is rapidly evolving. Traditional teaching for students, and dental professionals alike, is being replaced by newer technological alternatives. Generation Z students are now increasingly reliant on social media, e-books, flipped learning and online teaching throughout their undergraduate learning, and onwards to foundation training. This is an exciting and optimistic time. As GDPs adapt to this changing environment, we are hopeful that the topics we have discussed will allow for optimised learning and sharing of knowledge for current and future graduates in practice (Figure 2).