E-learning is introduced as a new method of education, with electronically supported learning and teaching process by a variety of instructional approaches such as online learning, mobile learning, blended learning, computer-assisted instruction, distance learning, e-teaching, simulation-based learning, and virtual learning. ¹ , ² , ³ , ⁴ To implement e-learning, universities need the equipment and infrastructure such as a proper Internet network, the necessary software, and hardware. In addition, organizational factors are necessary to implement indicators such as planning, information, monitoring, and evaluation. ⁵ This type of training requires technical skills in using electronic tools and understanding of electronic space and its functions. ⁶ The benefits of e-learning include learning at any time and place, sufficient opportunity to study, facilitation of educational processes, the possibility of reviewing the educational programs, and student-centeredness. ¹ , ⁶ , ⁷ However, less control over training, inflexibility, and difficulty of implementation in relation to clinical education (including preclinical and clinical dental education) are among the drawbacks and limitations of e-learning. ¹

Recently, the outbreak of the coronavirus disease-19 (COVID-19) over the entire world led the educational systems to move toward e-learning and virtual learning. ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ Since the education system of medical sciences, especially dentistry, is among the high-risk occupations associated with COVID-19, due to direct contact with the patient, concerns about the rapid spread of the disease were important changes for schools of medical sciences worldwide. ¹⁴ , ¹⁵ At the beginning of this epidemic, face-to-face medical educations were prorogated to reduce the spread of the disease and replace with e-learning. ¹⁶ , ¹⁷ In the meantime, e-learning in this era has faced problems and challenges for the world's medical universities, especially in developing countries. Iyer et al., in their study, discussed the impact of COVID-19 on dental education in the United States (US). ¹⁸ Deery reviewed the impacts of COVID-19 on the provision of dental education in the 67 dental schools in the US. The results of the study showed protecting the health of students, faculty, and staff; ensuring of dental education quality; ensuring confidence in health and safety measures. ⁹ Sarwar's study has been shown that in Pakistan, the level of satisfaction of dental students with the effectiveness of e-learning was significantly low due to the poor interaction of the teacher with the student. ¹⁹ Similar situations have been reported in the medical sciences of Jordan and the Philippines regarding the satisfaction of e-learning, and the status of technology infrastructure, interaction with students, and the acquisition of clinical skills. ²⁰ , ²¹ Yu-Fong Chang et al. showed the learning effectiveness of online class learning and physical classroom examination was better than that of traditional learning and examination in viewpoints of dental education. The study was recommended dental schools must improve their infrastructures and capabilities of human resources for the conduction of online courses to respond to the COVID-19 pandemic and the next crisis. ²² Cheng et al. showed that dental students were more worried about coronavirus disturbing their learning, improving financial pressure for their school, and being infected with Coronavirus and were more worried about the virus would continue. ⁸ Undoubtedly, comprehensive study and obtaining sufficient evidence in relation to the threats and opportunities in the educational method to achieve effective education is inevitable. Therefore, the present study was conducted to investigate the opportunities and threats of e-learning in dental education and to explore the experiences of dental faculty members in the COVID-19 epidemic condition.

The present study was a sequential exploratory mixed method (quantitative-qualitative). In the quantitative phase, a survey study was conducted to investigate the perspectives of faculty members four Iran, regarding the pros and cons of e-learning during the COVID-19 epidemic. A qualitative study with inductive content analysis approach was used due to the background knowledge about the phenomenon under study being insufficient and there is scattered knowledge about it. ²³

The study population comprised faculty members of four dental schools at Iran (n = 356). In the quantitative phase, the sample size was determined as 193 members of the dental based on the following formula: Z ²= 1.96, d ²= 0.45 and ɕ 10, and with a 10% increase, the sample size was 212. The inclusion criterion into the quantitative phase was defined by faculty members of dentistry schools who have experience of teaching (undergraduate programs) in didactic/preclinical/clinical teaching through e-learning (either synchronous or asynchronous) (at least 3 sessions). The faculty members who had no e-learning experience or <3 months of face-to-face learning experience were excluded from the study. As well as, incomplete questionnaires were excluded from the study (exclusion criteria). Participants who met the inclusion criteria were entered by stratified random sampling. Data collection continued until the completed questionnaires reached the number of samples.

Our criteria for inclusion of participants in the qualitative phase were (a) faculty members with teaching experiences in different settings of dental education and who were familiar with the educational approaches in dental education and (b) having prior experience in implementing e-learning education before the epidemic, (c) providing didactic/preclinical/clinical teaching through e-learning. Participants were selected by a maximum variation sampling strategy. In the phase, participants who achieved the lowest and highest score in the first phase participated in the qualitative phase.(n = 16).

Data collection

In the quantitative phase, data were collected using a questionnaire in three main sections. The first part, entitled Demographic Information, consisted of 10 items, and the second part included a questionnaire on e-learning threats and opportunities with 28 items in three categories. This questionnaire was designed by Khoshrang et al. ²⁴ (Cronbach's alpha = 0.81). In the third part, items related to the experience of using e-learning education in the dental school about various factors such as feasibility (applicability of e-learning in various departments of dental education and applicability of different resources in dental education) personal and system factors were asked. The validity and reproducibility of the related items in the third part were confirmed in the present study (Cronbach's alpha of 0.86). The electronic form of questionnaires by Porsline survey system was developed and sent through E-mail and social networks to the faculty members of dental schools. In addition, sending a reminder message was done two times to complete the number of samples.

In the qualitative phase, data were collected through individual semi-structured interviews. The semi-structured interview includes a blend of closed- and open-ended questions, often complemented by follow-up of why or how questions. ²⁵ All of the interviews were performed by a trained interviewer (F.K). The time of interviews was arranged with the participants prior to the interview. Due to the epidemic of COVID-19, the data collection was conducted through face-to-face (n = 6) and telephone interviews (n = 10). Before the interview, the researchers clarified the benefits of this study, in such a way that the purpose of the research, the interview method, and the right of individuals to participate in the study were explained to the participants. They were assured of the recording of the interviews and the confidentiality of the information and then their informed consent was obtained. During the data collection, all interviews were recorded. According to the interview guide, and to increase participants' credibility and confidence, all interviews began with the key question “Tell us about your e-learning experience” and “what steps you took in the e-learning process.” The probing questions were asked for additional clarification of the participants' experiences. In the qualitative phase, data collection continued until no new code was explored (saturation of data). Each interview lasted 45–70 min.

Data analysis

In the quantitative phase, the data were analyzed by descriptive indicators (frequency percentage, mean, and standard deviation) and the normal distribution of the data was checked by the Kolmogorov–Smirnov test. Student's t-test was used to compare the mean scores of participants' perspectives and the variables, which were defined in two groups such as gender, prior experiences of e-learning, experience in e-content production, and empowerment workshop. As well as, analysis of variance (ANOVA) was used to compare the scores of participants and variables with more than two groups such as age groups, dental specialty, academic rank.

In the qualitative phase, the inductive content analysis approach of Graneheim and Lundman was used to analyze the interviews. ²⁶

Based on the informed consent of the participants, all of the recorded interviews were transcribed word to word. The interviews were listened to several times and rechecked, reviewed the transcripts repeatedly to reach immersion in the data and make a sense of the data (the transcript of interviews lasted about 1600 min). Then, to extract the codes, significant short words and sentences were identified (meaning units) and codes were explored by taking notes in the margins of the transcription. The codes were then merged and placed in categories based on semantic similarity. After organizing based on the relationship between them, the theme was formed. In sum, based on the inductive content analysis approach, open coding started from specific codes and by combining them, more general and abstract expressions emerged as themes. In the present study, the qualitative analysis process was conducted through two people who qualified in qualitative methods and was supervised by an expert. In cases of disagreement over the coding, the analysis team members would discuss the codes until a consensus was achieved.

In this study, the trustworthiness of the data was confirmed by using semi-structured interviews, field notes, and lengthy engagement. The analyzing process and findings was reviewed by the research team (peer check). The extracted codes were reviewed by six participants (member check). In addition, the process of data analysis and code classification was thoroughly reviewed by two experts who had experience in the field of inductive content analysis (expert check). Moreover, the interviews were conducted in a specific and continuous period with full focus on the subject. All stages of the research, especially the stages of data analysis in all directions, were documented in detail. To facilitate the transferability of the findings, a clear description of the participants' characteristics was provided.

Ethical considerations

This study was reviewed and approved by the Ethics Committee at Shahid Sadoughi University of Medical Sciences (ID: IR.SSU. REC.1399.032).

In this study, 213 faculty members of dental schools in Iran country context participated, among whom 100 were male (46.9%) and 133 were female (53.1%). The participants have been involved in four universities including I (n = 58), II (n-53), III (n = 46), and IV (n = 56).

A Kolmogorov–Smirnov test indicates that the scores of participants' perspectives concerning the e-learning opportunities and threats follow a normal distribution, D (213) = 0.65, P = 0.79. Demographic information of the participants is reported in Table 1.{Table 1}

50 (23.5%) of the participants had experience in electronic content production before the onset of the COVID-19 epidemic, and 98 (46%) had previously participated in e-learning empowerment workshops.

The present results showed that the scores of the perspective of faculty members of dental schools regarding the e-learning opportunities and threats in dentistry were 4.05 ± 0.49. The scores of the perspective of faculty members were reported in domains; cost-effectiveness 4.15 (0.48), subjective factors 3.87 (0.41), teaching factors 4.15 (0.44), threat factors 4.05 (0.33).

The frequency of the participants' viewpoints for items is shown in Table 2. The results showed that the demographic characteristics of the participants did not differ significantly in their perspective (P > 0.05). The results of ANOVA test showed that there was no significant difference between scores of dental faculty members' perspective on the opportunities and threats of e-learning and age groups (P = 0.25), dental specialty (P = 0.46), professors' academic rank (P = 0.63). In addition, the results of Student t-test showed that there was no significant difference between faculty members' perspective and gender (P = 0.33), prior teaching experience of e-learning (P = 0.43), experience in e-content production (P = 0.85), and experience of empowerment workshop (P = 0.17).{Table 2}

The majority of participants believed that oral pathology, oral and dental diseases, social dentistry and dental health, dental materials, and oral and maxillofacial radiology are better in terms of implementing e-learning than other disciplines and can provide more of their training virtually and electronically Table 3.{Table 3}

In this study, feasibility by means of the applicability of e-learning in various departments of dental education was assessed from the viewpoints of participants Figure 1. Figure 1

Percentage of participants' agreement about feasibility of e-learning in different dental departments in viewpoints of dental faculty members during the coronavirus epidemic.

The present results showed that the status of e-learning for dentistry from the participants' viewpoint is considered as an opportunity. Creating the necessary infrastructure and empowering faculty members about e-learning and blended learning methods ²⁷ can be a valuable opportunity in dental education.

The results showed that the use of e-learning in dentistry was considered as an opportunity due to the low economic burden, greater access, and lack of space and time constraints for learning. However, the e-learning infrastructure such as the internet and access to e-tools influence the lack of supply was a threat in this process. In this regard, the qualitative results showed the limitations of e-learning infrastructure; the weakness of e-learning in clinical dental education is major challenge. These increase the need for proper blending of face-to-face and e-learning. Participants believed that e-learning was not appropriate for all dental education courses. Deficiency of e-learning in clinical education, insufficient infrastructure, limitations of observation, and interaction with real patients in e-learning is some of key barriers that have been a serious threat to e-learning in dentistry. Participants stated that the limitation of creating an interactive triangle in the educational process among teacher-student-patient, as well as, in appropriate educational design, weakness in teaching skills, learner assessment, and evaluation is explored as e-learning challenges. The results of various studies showed e-learning as an effective method to support traditional education but were not acceptable as an alternative. ²⁸ , ²⁹ The usefulness of e-learning depends on the educational objectives at the desired knowledge or skill levels. For example, diagnosis skills using online education provide better learning opportunities and automatic feedback. ³ The effectiveness of e-learning in psychomotor objectives needs further investigation. ³ , ²⁸ , ²⁹ Participants in the study found the use of e-learning to be more effective in specialized areas including pathology and oral and maxillofacial diseases, oral health and dental materials, and oral and maxillofacial radiology. In line with our results, Botelho et al. showed that using e-learning is introduced an effective method for learning of visual diagnosis skills. ³ It seems that the topics in the sections are mainly based on the cognitive domain, and e-learning can provide a good opportunity to develop diagnostic and decision-making skills among learners. Regarding the tools used, the quantitative results showed that more than 50% of the participating faculty members agreed with the use of PowerPoint, instructional videos, animations, texts, and online classes in dental education. The use of PowerPoint and texts were more common in dental schools, the use of online classrooms, instructional videos, and projects was second level. Despite the importance of the use of a problem-solving approach to develop high levels of cognition, teachers mostly used noninteractive tools that focus on providing knowledge. This can be due to limited facilities, lack of familiarity with e-learning technologies, and virtual reality in dentistry. Given, dentists are expected to have good capabilities in a high level of cognition for patient diagnosis and management, the use of interactive tools based on problem-solving and simulation is recommended. ³⁰

The category of affective and communication factors addressed teacher-student, learners' interaction with each other and with the teacher. The present results showed reducing the relationship between teacher and student, reducing student monitoring, and diminishing role models were identified as a threat in viewpoints' of dental teachers that are consistent with qualitative findings. Participants stated that the human resources involved in providing e-learning services did not acquire basic skills and competencies. E-learning faced challenges such as teachers' resistance to using new approaches and educational technologies due to lack of basic competencies and demotivation due to lack of belief in the effectiveness of this type of education in dental schools. Participants cited a lack of understanding of the need for e-learning before the outbreak of the COVID-19 virus and a lack of compulsion to use e-learning in schools as one of the reasons they were unprepared to use e-learning during the COVID-19 era. They argued that although supportive activities had previously been taken in the universities of medical sciences to use a blended and electronic approach, due to the lack of understanding of the need at management levels and faculty members, empowerment programs and moving toward using this approach was slow and was not prepared them for using e-learning during the Corona era. Likewise, Chavarría-Bolaños et al. showed teachers need to empower the application of virtual strategies and technology in e-learning. ⁴ Bjekic D et al. in their study stated that empowering teachers in the e-learning process have an important role in the success of e-learning. ³¹ Learners were also a key factor whose capabilities as an e-learning user are important. Participants believed that unfamiliarity with learning management systems, and how to work with educational tools and technologies, weakness in self-directed learning skills were among the threats to e-learning development. In addition, the habit of teacher-centered culture, lack of motivation, and noncompliance with the requirements of learning in the e-learning process explored the threats of e-learning. The lack of a culture of using the e-learning methods, the weakness of development of self-directed learning skills, being a good e-teacher and the use of educational technologies have caused many difficulties in the development of e-learning in the Corona era. The results of the study by Eslaminejad et al. have introduced educational and technical factors as two main factors in e-learning education. ³² Familiarity with the learning management system, and new technologies, the ability to produce electronic content for teaching in the technical preparation of teachers must be considered. In Eslaminejad's study, the readiness of teacher for e-learning was assessed at a moderate level. ³² The results of Kim's study showed that teachers' attitudes toward the use of e-learning was not positive and the individual and systemic factors in teachers' resistance require further study. ³³ Organizational support increased awareness and empowerment of faculty members on how to integrate e-learning into curricula are recommended. ³³ Similarly, systemic problems, lack of e-learning rules aimed at increasing the efficiency of education among teachers and students were explored as threats in the present study. Participants believed that the lack of planning at the managerial and individual levels for e-learning is a key obstacle to the development of efficient e-learning. Therefore, creating rules and support mechanisms at the management level along with empowering people to play the role of e-teacher and e-learner, as well as creating a constructive culture at the various levels of educational systems as solutions for the development of e-learning is suggested.

Participants identified the use of blended education in dentistry as an appropriate opportunity for schools. They identified the use of diverse teaching-learning techniques, the ability to access educational resources, and expertise teachers the possibility of reviewing and learning topics over and over as valuable opportunities in e-learning at dental schools. Lack of problem-solving skills and poor learning skills among learners in virtual situations were explored as e-learning challenges in dentistry. The results of Ali Baig et al. study showed that students and teachers mostly used asynchronous blended education in dental school. In this study, the use of e-learning is introduced as an educational supplement to move toward lifelong and self-directed learning based on the competency-based approach. ³⁴ In the study, Asiry et al., students suggested the blending of traditional education and e-learning as the best option and the provision of internet and computer infrastructure are important to conduct the method. In this study, the acceptability and applicability of e-learning in dentistry from the viewpoint of students were emphasized, ³⁵ which is consistent with the present results from the viewpoint of teachers.

Limitation

The limited sample size and type of sampling restricts the generalization of results. The lack of response to the questionnaires on time, which continued with repeated reminder calls and messages until the required sample size was completed. In the present study, the perceptions of faculty members were assessed and the viewpoints of learners in the postgraduates and Ph.D. dental students were not considered. The second part of the present study was conducted by the qualitative method, which can decrease the generalizability of the findings.

The results showed the faculty members of the dental schools agreed with the use of e-learning in dental education process and considered it an opportunity. From the viewpoint of dental teachers, the acceptability and usefulness of e-learning in didactic and preclinical courses of dental education are desirable. Instructional design is recommended for the purposeful blending of face-to-face and e-learning, creation of appropriate infrastructures and empowerment of human resources (e-teacher and e-student) which was introduced requirements for the development of e-learning in dental schools.

Financial support and sponsorship

This project was funded by Shahid Sadoughi University of Medical Sciences, Yazd, Iran (Grant No. 7949).

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.