Dentistry is a profession where consistent accuracy is required. A dentist's judgment on skills, the setting where s/he practices, and the technology used affects the lives of many. Industry has taught us that to limit the adjustments and decisions a worker makes in manufacturing a product produces a product with fewer defects. Why should we think that dentistry is any different? Changing the tilting dental chair environment, which allows

Figure 1  Morita's Feel-Ease

many adjustments and decisions, to an environment in which the dental patient support provides a stable reference for balanced operator positions limits adjustments and decisions during dental procedures and enhances the dentist's performance. The non-tilting patient support requires advanced skills in order to function optimally. New rules for the performance of motor tasks in dental procedures are self-derived using ones own proprioceptive feedback as well as self-modeling feedback via tracking cameras. The Skill Acquisition, Transfer, and Verification (SATV) model of developing psychomotor skills was developed by American dentist, Dr. Daryl R. Beach, through research and development at the Human Performance and Informatics Institute in Atami, Japan. The SATV system provides the most direct and reliable way in which students derive for themselves the way they want to practice throughout their career. SATV is divided into progressive stages of cognitive development starting with 0 for information and basic concepts through 6 which considers the inter-actions of the entire dental team and patients in clinical situations.

In the "Skill Acquisition" phase, students model and record the body positions and setting requirements that are compatible with the highest level of clinical performance that can be imagined. These conditions minimize the physical stress a dentist will experience during their career. These derivations are then used to adjust the SATV clinical setting to his or her unique body dimensions for optimal care delivery. Specific skills are acquired in simulating clinical acts using a simulated head, teeth, and pathologies. Immediate

Figure 2  SATV Teeth

feedback is provided through CCD camera and digital/video recording for the frequency and the extent of variation from one's self-selected optimal performance positions. Reference points on teeth and gingiva simulate areas most critical to an examination and treatment. These points enable an objective means to self-evaluate the body conditions and articulations that are most secure.

The "Skill Transfer" phase emphasizes that the acquired basic skills may be applied to clinical procedures such as oral examination, extraction, anesthesia, tooth cavity restoration, full denture construction, root canal treatment, crown preparation, casted partial denture procedures, etc. An imaginary vertical axis through the incisive embrasure of the patient's central incisors is established from awareness of comfort and optimal use of human body during simulation.

This awareness is reinforced by the design of an orbiting operator support in the preferred equipment model, the Feel-Ease (Figure 1). The consistency of positional relationships provided through simulated clinical procedures is best transferred to daily clinical practices by maintaining the clinical setting the same as the pre-clinical setting. Therefore, any student who has difficulty in clinical practice should come back to the SATV skill acquisition phase repeatedly until he/she has more confidence. This process is similar to the experience of an airline pilot in a flight simulator. A new cockpit requires experience in a new simulator.

Skill verification by means of multimedia CCD camera, digital/video records or data forms, and standardized simulated pathologies, of skill acquisition and transfer is used throughout the system. Green reference surfaces within simulated teeth enable an objective means to self-evaluate the accuracy of intraoral outcomes. These surfaces are imbedded around simulated caries in the transfer phase. Once a procedure is finished the remaining overcut lines or marked surfaces and remaining caries are measured. The measurement of the

Figure 3  DentSim (by DENX)

amount of overcut or undercut surfaces are a means to verify ones own accuracy (Figure 2). This verification will ensure that skills have been acquired and that they are used consistently at the highest level when transferred to patient care.

What is critically important in pre-clinical dental school experiences is that: 1) the student be given the opportunity to derive for her/himself the conditions s/he prefers to practice with for the rest of their career and 2) the student be given those environments to develop his/her skills. Currently, most dental schools in the United States are establishing simulator settings with little or no regard to proprioceptive derivation or self-modeling. A very popular modeling environment, DentSim (Figure. 3), offers digitally monitored simulated oral performance but places the student in a chair-mounted over the patient delivery system with no feedback for their body conditions. The best placement of dynamic instruments and the skills to use them are being ignored. Most dental schools emphasize product and not process. The dental student's performance is left to trial and error with emulative examples, which are not the best way to acquire skill.

Japan, on the other hand, has included SATV training in the curriculum of 23 out of their 29 dental schools. Much of this attention is due to the presence of Dr. Beach in Japan and the local manufacturing of the

Figure 4   SATV Simulator (by Morita Corp)

instruments and equipment conducive to this technique. Thammasat University in Thailand has a new dental school based entirely on the Beach philosophy. It's communication network is run by a scaled based LAN software that includes SATV for students, faculty, and staff in areas of performance not only in the clinical arena. The Institute of Dentistry at the Medical School of Lodz, Poland also has established a SATV program. SATV (Figure 4) offers a cognitive advance in that the task's outcome accuracy and body conditions necessary to complete a task are monitored simultaneously and the kinesthetic positioning of patient, operator, and instrumentation are self-derived by the student.