Dental Students’ Perceptions Towards E-learning in Comparison With Traditional Classroom Learning

Introduction: Electronic learning (e-learning) has evolved into a popular educational approach since the coronavirus disease 2019 (COVID-19) pandemic. While this represents an additional model for teaching, traditional classroom learning fosters the development of interpersonal skills and enables students to share and discuss specific topics. However, existing research on the comparison of both these modes of learning in the field of dental education is inadequate. This study aimed to evaluate the perceptions of dental students towards both electronic and classroom learning. Methods: A cross-sectional questionnaire-based survey was conducted between November 2022 and January 2023 among dental students in Saudi Arabia. Students were questioned on their comparative perceptions of e-learning and classroom learning before, during, and after the COVID-19 pandemic. Questionnaire responses, including demographic data, were collected and tabulated, using electronic data management software. The tabulated data were analyzed to provide descriptive statistics and compare electronic and classroom learning with demographic variables and previous experience with e-learning. Results: Most respondents reported possessing average information technology (IT) skills and prior experience with e-learning. Blackboard Learning Management System (LMS) (Reston, VA: Blackboard Inc.), Zoom (San Jose, CA: Zoom Video Communications Inc.), and Microsoft Teams (Redmond, WA: Microsoft Corporation) were the most commonly used and advantageous e-learning platforms. While the majority of participants found both methods acceptable for problem-based learning sessions and theoretical lectures, they reported e-learning to be less effective than classroom learning for clinical and practical sessions. Regarding e-learning as a preferred method over classroom learning, most responses were "neutral" or "uncertain." Comparing the mean ranks of the ordinal responses for the different teaching methodologies and the nominal responses for e-learning as the preferred method, no statistically significant interactions were observed for demographic characteristics, IT-skill levels, or prior experience with e-learning. Conclusion: Although enhanced performance and learning capacity are enabled through e-learning, the advantages of personal interactions and the feasibility of practical and clinical dental sessions are achieved only through classroom learning.


Introduction
Electronic learning, or e-learning, is also referred to as web-based, online, distributed, computer-assisted, or Internet-based learning.It is a system of education wherein learners acquire information through the Internet and web-based applications.E-learning employs a pedagogical approach that demonstrates student-centered flexibility and facilitates student-faculty collaboration, despite the physical divide [1].Over the last decade, e-learning has emerged as a popular teaching approach and represents a model for the effective delivery of education [2].With the advent of high-speed internet and advanced web-based technologies, e-learning can utilize electronic tools and devices that ensure a smooth transformation from the traditional classroom learning model [2].Because e-learning is based on remotely stored resources and lectures delivered from any location or as recordings, it enables greater accessibility and review of course content [3].Furthermore, the digital nature of e-learning enables students to learn about the latest developments in their field of study apart from the knowledge acquired from their course content and classroom interactions [1].
A key attribute required for e-learning is technological literacy in operating computers and digital devices, which is further enhanced by prior exposure to e-learning through any one platform [4].Although e-learning has been used in medical education for almost two decades, it has predominantly been employed as a teaching aid, which complements the knowledge and information acquired through face-to-face learning  [5].However, during the coronavirus disease 2019 (COVID-19) pandemic-induced lockdown and the ensuing physical distancing measures enforced worldwide, students and faculty members had no choice but to use elearning as the only method of teaching [6].Research has indicated that in this fast-paced and developing world, e-learning could emerge as a valuable teaching tool to continue education during crises, such as pandemics and wars [7].While this was indeed beneficial during the COVID-19 lockdown, as educational programs in schools, colleges, and universities could continue without a break, challenges were encountered in the fields that require practical and psychomotor skill-based learning [8].
Personal interaction and frequent reinforcements are essential for any knowledge-sharing session aimed at cognitive and psychomotor skillset development [9].Medical education, in general, and more specifically, dental education, is a learning system that emphasizes on didactic teaching and hands-on practical and clinical teaching.This includes practical sessions on laboratory models, problem-solving sessions based on clinical case-scenarios, and clinical sessions, wherein comprehensive dental treatment is provided by students under supervision [10].Classroom learning facilitates the development of interpersonal relationships, enabling students to share and discuss their individual perceptions on a topic [11].However, this traditional learning environment often lacks opportunities for repetitive learning and continued access to resources [12].The aforementioned gap is largely filled by e-learning, wherein students are empowered to learn at their own pace and master the details of the study topic by reviewing course content, which is often recorded and stored online [11].Moreover, the psychological well-being of students is challenged by elearning and online education owing to isolation and a lack of student-faculty interaction [13].
Given the available evidence in the literature, it is interesting to note that both e-learning and classroom learning have their respective advantages and disadvantages.However, evidence comparing e-learning and classroom learning is unavailable for the area of dental education, which involves the development of competencies related to knowledge, cognition, and psychomotor skills.Particularly, considering scenarios, such as the recent COVID-19 pandemic lockdown, it is imperative to know more about student perceptions of e-learning as a methodology for dental education and its efficacy compared with traditional face-to-face classroom-based methodologies.Therefore, this study aimed to evaluate the perceptions of dental students about e-learning in comparison with traditional classroom-based learning.

Materials And Methods
The present study was designed as a cross-sectional survey from November 2022 to January 2023 to evaluate dental students' perceptions of e-learning in comparison with traditional classroom-based learning in light of their experiences before, during, and after the "COVID-19 pandemic."Dental university students in Saudi Arabia were the target population for this study and formed the sampling frame.The dental teaching curriculum in Saudi universities is spread over six years, with the first two years focusing mainly on didactic teaching.While simulated practical training on phantom models begins during the second year and progresses up to the fourth year, clinical training begins in the third year at a 50% level and increases gradually during the fourth and fifth years to reach 100% clinical training during internship [8].Accordingly, students who had enrolled in their respective universities and completed at least one year of classes before the COVID-19 lockdown was imposed were included in the study.The following were excluded from the survey: the students who had dropped a course or semester during the lockdown because of technical or medical reasons and those who encountered the lockdown within a year of enrollment in the university.For the given study sampling frame, the sample size was estimated using "G*Power" open-source statistical software (version 3.1.9.7, 2020) (Düsseldorf, Germany: Heinrich Heine University Düsseldorf).Assuming an effect size of 0.3, alpha set at 0.05, and statistical power at 0.9, the desired sample size was estimated to be 240 participants [14].
Following an in-depth literature review, the research team prepared the survey questionnaire, altering it, based on the feedback received during the pilot phase, to ensure that the final survey questionnaire precisely collected the desired information from the target population.Survey questionnaires were distributed electronically, and delegated team members collected in-person data.This study aimed to evaluate the research question, both qualitatively and quantitatively.
Furthermore, the questionnaire consisted of four main parts as follows: (1) participants' demographic information (age, gender, year of study in dental school), proficiency in IT skills (including but not limited to access and interaction using internet-based learning applications either through a personal computer or a handheld digital device), and prior experience with e-learning [11,15].(2) Participants' exposure to different e-learning platforms and their overall perception of the advantages of e-learning and classroom learning, with the ability to respond to multiple choices.(3) Students' perceptions of e-learning and classroom learning for different teaching methodologies, including problem-based learning, theoretical lectures, clinical sessions, and practical sessions, wherein simulated clinical and practical sessions were acceptable.Participants ranked their responses on a four-point ordinal scale, namely, "e-learning is as good as classroom learning," "e-learning is better than classroom learning," "both learning methods are acceptable," and "e-learning is poorer than classroom learning."(4) Student responses on e-learning being preferable over classroom learning.Participants ranked their responses on a five-point nominal scale, namely, "strongly disagree," "disagree," "neutral/uncertain," "agree," and "strongly agree."

Data collection and statistical analysis
The data obtained were analyzed using the IBM SPSS (version 26.0 for Windows-based operating system) (Armonk, NY: IBM Corp.).Descriptive statistical analysis (mean, standard deviation, frequencies, and percentages) of the data obtained was conducted for the categorical and quantitative variables.The nonparametric Mann-Whitney U test was used to compare the mean ranks of the ordinal and nominal scale responses across the categorical study variables with two categories.For variables with three or more categories, the non-parametric Kruskal-Wallis test and the Conover test (for post-hoc analysis), were used to compare the mean ranks of ordinal and nominal scale responses across categorical study variables.For all statistical tests, the significance level was set at 95%, and any p-value less than 0.05 was considered statistically significant.

Results
Descriptive analysis revealed that out of the 250 study subjects, 26 (    # Simulated clinical/practical sessions for e-learning. When participants were asked to respond to e-learning as a preferred method over classroom learning on a five-point nominal scale, most responses were neutral or uncertain.There was a unanimous agreement (agree/strongly agree) recorded in favor of e-learning, primarily because of its ability to cover course objectives and classroom learning (44%) within prescribed time, and also its modern nature (58%), and the lower time and effort associated with using it (60.8%).Conversely, there was general disagreement among participants (strongly disagree/disagree) on e-learning leading to better student-faculty interaction (57.2%), or facilitating student participation, when compared with classroom learning (40.4%) (Table 4).

TABLE 4: Participant responses towards e-learning as a preferred method of learning over classroom learning ranked on a five-point scale (n=250).
Comparing the mean ranks of the ordinal responses for the different teaching methodologies of e-learning and classroom learning with the categorical variables, no statistically significant interaction was observed, except for the level of study in theoretical lectures, and the level of IT skills in practical sessions (Table 5).
Regarding the level of study, students belonging to the junior levels (third, fourth, and fifth years), rather than interns and post-graduate students, preferred classroom-based lectures.Similarly, students with selfperceived below-average IT skills lacked the confidence to gain knowledge through practical e-learning sessions, even though they were simulated.# Simulated clinical/practical sessions for e-learning.

COVID-19: coronavirus disease 2019
When the mean ranks of the nominal responses for e-learning as a preferred method over classroom learning were compared with the categorical variables, no statistically significant interactions were observed for demographic characteristics, IT skill levels, or prior experience with e-learning (Table 6).

Discussion
Effectiveness of educational study models is often assessed using three primary characteristics as follows: student study experiences, synchronous student participation, and faculty-student interaction [16].In any interactive learning process, students develop knowledge, skills, and new research ideas through active and synchronized participation in the course, and interaction is facilitated by the faculty members [17].
Traditional classroom learning models are face-to-face and didactic in nature, wherein the prescribed study material is handed over to students through lectures, faculty-student discussions, and study handouts [10,18].On the other hand, e-learning is relatively asynchronous, because of a physical gap in communication between faculty and students, thereby leading to remote communication of course content and study materials [7].Nevertheless, with the advancement in technology relating to internet-based audiovisual aids, such as chat, virtual classrooms, and online meeting platforms, e-learning has evolved to be more synchronous than before [7].In light of the extensive use of e-learning during the recent COVID-19 pandemic-induced lockdowns and mandated closures of dental and medical schools, it is alluring to ask the question if electronic learning will predominate over classroom learning in the near future.Therefore, the present study evaluated student perceptions regarding e-learning in comparison to classic classroom learning, with a focus on dental education at public universities in Riyadh, Saudi Arabia.
Integration of the dental curriculum with e-learning was a welcome sign during the COVID-19 pandemic.However, the advantages and disadvantages of the replacement of traditional classroom learning with e-learning, especially in the context of dental education, require thorough analysis.The dental curriculum in Saudi Arabia extends over a period of five years and includes exclusive didactic learning methodologies in the first and second preclinical years, followed by three years of combined clinical and didactic training.In addition, dental students undergo training for psychomotor skills through the simulation of laboratory phantom models [8].Over the past few years, several dental institutions in Saudi Arabia have introduced online platforms, such as Blackboard LMS, which were used mainly for theoretical interactions and delivering written assessments [8].However, this always involved a combined strategy, wherein face-to-face training was always part of the learning methodology [19].It was reported as early as 2008, that adopting elearning as a standalone teaching platform for medical or dental education should only be considered after evaluating the benefits to the student community and its degree of adaptability at large [20].However, a paradigm shift towards e-learning as a prime teaching modality of the dental curriculum occurred due to circumstances surrounding the COVID-19 pandemic [11,13].
In this study, the ability of e-learning to provide learners with materials that are accessible at any convenient time for self-instruction and collaborative dental education was reported as advantageous.Nevertheless, while this type of asynchronous learning is more beneficial for students in their early dental school years, it could pose challenges for students undergoing practical or clinical courses, and postgraduate fellows and residents with clinical rotations.Especially considering the fact that almost all clinical courses, either at the undergraduate or at the postgraduate levels, are associated with limited hours of hands-on training and mandatory curriculum requirements [21].The complexity of the dental curriculum and the lack of technical expertise among faculty members to provide simulated practical and dental clinical training have restricted e-learning.The current study observed that most students in the clinical year were disappointed with this mode, expressing difficulties in coping with practical and clinical sessions.In the future, the orientation of faculty and administrators in system deployment, content development, and designing learning pathways and programs is vital to support the replacement of classical face-to-face learning by e-learning [22].Interestingly, the evolution of virtual patient simulations and high-impact elearning materials has encouraged educators and learners to adopt this new learning platform [23].
E-learning platforms currently focus on individualized (adaptive) and collaborative learning, and they transform educators from disseminators to facilitators [24].The present study sample appreciated e-learning as being advantageous in terms of personalized content delivery, identification of the students' potential, and constant monitoring of their progress [25].Advanced communication platforms have enabled more interactive and collaborative e-learning experiences [15].The study participants found noticeable improvements in the level of knowledge, assimilation of current concepts, fulfillment of designated course objectives, and students' satisfaction with e-learning, which may lead to transformations, even in the prevailing clinical protocols [26].However, the paradigm shift to the new platform is questionable because of the continuous learning required in dental education, along with clinical and practical competency development to adapt to evolving technologies in dental management [27].It is in this context that clinical learning is best achieved through face-to-face interactions, as it helps students gain professionalism about the compassionate expressions and body language that should be adopted during patient handling [28].This has been reiterated in an earlier study, wherein medical students get trained in perceiving visual information relating to subtle emotions only through face-to-face interaction and never from reading texts or attending lectures [29].The same sentiment was echoed with respect to clinical training in the present study findings too.
In recent decades, e-learning has gained importance in dental education, with students becoming more acquainted with the internet and gadgets, such as computers and smartphones [6].Garnering essential IT skills has become an imperative part of not only learning activities but also for day-to-day lifestyle and sustenance.In the present study, self-reported IT skills based on an individual's own assessment were carried out to provide their personal judgment and feedback as to how well they are capable of handling ITbased interactions.The sample group demonstrated a high level of command in IT skills and used Blackboard, Zoom application, Microsoft Teams, and Google Rooms, with relative ease and confidence.However, even today, most students in master's programs use e-learning platforms only in literature searches for thesis completion [30].Hence, compared to other fields of education, dental students are still at a nascent stage with respect to e-learning [31].Current statistics indicate that academicians have increased in number, as the dental fraternity becomes increasingly popular [31].Therefore, continuous updates are mandatory for the faculty handling e-learning platforms [32].The quality of dental education and student satisfaction is dependent on proper design, teaching, and tutoring in updated e-learning platforms [33].
Traditional classroom learning possesses the advantage of face-to-face interaction and tutor support, which e-learning platforms do not offer [32,34].Therefore, although problem-based learning (PBL) and theoretical sessions did not differ much between the two modes of teaching, accommodating practical and clinical sessions in e-learning was challenging.However, with advances in technology, faculty and students should accommodate these changes and update their IT skills [22,33].For transformation into an e-learning platform for dental education, students' comfort and motivation in grasping IT concepts should be assessed to avoid skepticism [35].Furthermore, since e-learning is more prevalent in English, language barriers may hinder its implementation as the primary teaching modality [6].Educational institutions should provide academicians with the resources, adequate equipment, and necessary manpower to successfully incorporate e-learning into the present system [3].
Whether we prefer it or not, digital trends are bound to be the norm rather than the exception in the near future.Especially with the advent of generative artificial intelligence (AI), learning at a self-styled pace with the help of AI chatbots and applications is no longer a utopian reality [36].In light of these developments, it is imperative that e-learning is blended into mainstream traditional learning for all streams of education and curricula.Although it is easier to incorporate e-learning for self-study and lecture-based learning, it should be taken further toward cognitive learning through problem-solving and scenario-based learning methodologies.This has already been experimented with and implemented for medical education, which does not require training in psychomotor skills [7,22].As for practical and clinical training of psychomotor abilities, such as that required in the dental curriculum, further research and development need to be directed towards the development of the same.

Conclusions
This research revealed the preferences of dental students through a detailed comparison of the traditional classroom and e-learning modalities, including an assessment of various aspects of PBL, practical and clinical sessions.While e-learning enables enhanced performance and learning capacity, the advantages of personal interactions and the feasibility of practical and clinical sessions are achieved only through the classroom model.Periodic evaluation of students' satisfaction and their effective coping mechanisms with newer teaching methods will help prioritize learners' interests and enable comprehensive improvement in the education system.

Table 1 .
10.4%) were younger than 21 years and 179 (71.6%) were in the age group of 22-25 years.With respect to gender distribution and nationality, 119 (47.6%) respondents were male and 241 (96.4%) were Saudi nationals.Based on the year of study at the dental school, 43 (17.2%) were studying in the third year, 74 (29.6%) in the fourth year, 57 (22.8%) were fifthyear students and the remaining 76 (30.4%) were interns and post-graduates.Most participants demonstrated an average level of IT skills (n=182, 72.8%) and reported prior participation and experience with e-learning activities (n=138, 55.2%).Descriptive statistics of the categorical variables are presented in n (%)Age of the participants (years)

TABLE 1 : Participant demographics and their experience with e-learning (n=250).
advantages of classroom learning.Practicing self-discipline (34.8%), minimal distractions (36.4%), scope for social interaction (27.2%), and school-based learning conditions (20.8%) were seen as advantages of classroom learning by only a few participants (Table2).Categories of participant responses # n (%)Different e-learning platforms and digital tools used

TABLE 2 : Participant responses towards usage of different e-learning platforms and digital tools and the advantages of e-learning and classroom learning (n=250).
6%).The detailed frequencies of the participants' responses comparing e-learning and classroom learning for the different teaching methodologies are presented in Table3.Ranked responses for different teaching methodologies n (%)

TABLE 6 : Effect of demographic characteristics and previous digital learning experience on the mean ranks of participant responses towards e-learning as a preferred method of learning over classroom learning.
A higher mean rank score indicates preference for e-learning.COVID-19: coronavirus disease 2019