A Systematic Mapping of Serious Games for Oral Health

Rafael de Andrade Pereira

, Vinicius Schultz Garcia da Luz

, Simone Nasser Matos

Rui Pedro Lopes

and Helyane Bronoski Borges

Computer Science Dept., Federal University of Technology, Paraná (UTFPR), Ponta Grossa, PR, Brazil

Research Center in Digitalization and Industrial Robotics, Instituto Politécnico de Bragança (IPB), Bragança, Portugal

Keywords: Game-based Learning, Oral Health, Systematic Mapping.

Abstract: Oral health in the daily lives of individuals allows health promotion and prevention. Oral health literacy is

fundamental to enable people to have the knowledge and be aware of its importance, enabling them to process,

evaluate and apply information on this topic. Serious games, in the educational domain, can be used to assist

in this literacy. This article carries out systematic mapping of these games in the field of oral health. The

mapping included work carried out in the last 5 years and indexed in four repositories. As result it was found

that there are few serious games for oral health, and few have a well-defined process for learning.

1 INTRODUCTION

Oral health, despite being an important part of

physical health, still receives little attention. Kisely

(2016) conducted a study and found that serious

mental illnesses, affective and eating disorders can be

associated with dental problems such as tooth decay

and periodontal diseases. These diseases can lead to

tooth loss and the problem can be aggravated due to

the use of medication.

A bad dentition can lead to problems with

chewing which can impair nutritional intake (Kane,

2017). One way to help solve this problem is to

provide individuals with Oral Health Literacy (OHL)

(Baskaradoss, 2018). Literacy allows understanding

and acting on health issues (Sorensen et al., 2012),

allowing for a better quality of life (Martins et al.,

2015). Ratzan and Parker (2000) report that health

literacy promotes the “ability to obtain, process, and

understand basic health information and services

necessary to make appropriate health decisions”.

However, how to provide oral health education in a

more interactive way in order to provide individuals

with their literacy?

https://orcid.org/0000-0003-2997-5082

https://orcid.org/0000-0002-9616-3503

https://orcid.org/0000-0002-5362-2343

https://orcid.org/0000-0002-9170-5078

https://orcid.org/0000-0002-9153-3819

Educational or serious games are interactive tools

that assist in the development of skills and learning.

Their main objective is to consolidate knowledge

instead of simply encouraging entertainment. This type

of games encompasses three main characteristics: they

provide a learning environment or tool, usually based

on an interactive media simulation, and are based on

game mechanics and elements. The game elements are

related to the operating dynamics and mechanics of

how the player interacts and progresses through a

game. Their components are environments, scenarios,

characters or representation of the player (Gunter,

Kenny, & Vick, 2008).

Serious games have a dynamic to transmit

concepts and situations aligned with work, education,

health, safety, sports, among others, which allow

simulating recreational experiences closer to reality.

However, they are aimed at a particular audience in

which specific knowledge concerning the area they

are applied (Mello & Zendron, 2015). Bigdeli and

Kaufman (2017) proved that the closer a game is to

the educational environment or the student's own

reality, the more productive learning will be.

Serious games seek to keep at a maximum the

ability of a player to solve certain problems, even if it

400

Pereira, R., Garcia da Luz, V., Matos, S., Lopes, R. and Borges, H.

A Systematic Mapping of Serious Games for Oral Health.

DOI: 10.5220/0010502304000407

In Proceedings of the 13th International Conference on Computer Supported Education (CSEDU 2021) - Volume 1, pages 400-407

ISBN: 978-989-758-502-9

is allowed to choose the levels of difficulties or until

the player becomes an expert on the challenges of the

game. These games are designed to enhance

individual skills and improve some aspects of

learning (Hägglund, 2012).

The work described in this paper performs a

systematic mapping to obtain an overview of the

studies already conducted on the theme of serious

games in the context of oral health literacy. The

mapping was carried out in the time frame from 2015

to 2021 and used the method of Kitchenham and

Charters (2007). Four search repositories were

considered: ACM, Scopus, IEEE Xplore and SciELO.

2 SERIOUS GAMES

The use of serious games promotes interactive and

explicit learning, as knowledge is developed through

experiences obtained during interactions and can be

transferred to other activities in the real world. These

games adopt several strategies to promote cognitive

skills in which students learn by performing activities

and engaging with appropriate content and contexts

(Mello & Zendron, 2015).

Games can be framed as a didactic tool of

educational support, in which different contents can

be approached in an interactive and efficient way,

potentiating the development of knowledge on a

certain subject (Ferreira et al., 2018).

Serious games seek to keep players in an

interactive learning circle to motivate them in

creating and proposing different solutions to solve

problems or challenges; otherwise, there will be

abandonment in solving the challenges (Eck, 2015).

The classification of serious games is based on the

criteria of gameplay, purpose, market, and target

audience. However, many games can be categorized

on the gameplay criteria due to their complexity,

rules, challenges and objectives (Alvarez, Djaouti &

Rampnoux, 2020).

In the study by Garmen, Pérez, Redondo, and

Veledo (2019) two tools that apply serious games

were evaluated: Cuibrain (Studios and Cuicui, 2020a)

and Boogies Academy (Studios and Cuicui, 2020b).

The first application uses mathematics and literacy to

assist in the development of multiple intelligences,

such as memorization, concentration, coordination

and attention. Boogies Academy, on the other hand,

offers several serious games with activities of logic,

biology and music, with the objective of improving

cognitive skills and also checking the emotional state

of the player during interactions.

Garmen et al. (2019) found that from a sample of

372 students from the first to the third grade of

elementary education, the use of serious games

helped to reduce the level of anxiety during the

interactions with the tool. The authors concluded that

by using the tool, it is possible to stimulate multiple

intelligences even of students who have learning

difficulties.

Thus, the application of serious games can

improve cognitive skills bringing students closer to

real-world activities and experiences.

3 ORAL HEALTH

An individual's well-being is associated to daily

activities such as eating, talking, smiling, among

others. Oral health is an integral part of this well-

being (Baiju, Peter, Varghese, & Sivaram, 2017). For

this reason, oral problems can negatively impact the

performance of activities and people's quality of life.

Oral diseases and their complications can cause

deprivation and psychological constraints on the

individual (Ju et al., 2017).

Baskaradoss (2018) conducted a study and found

that people who have a low level of OHL had worse

periodontal health. The author states that improving

individuals’ OHL can help with their self-

management skills and also with overall treatment

outcomes.

Sipiyaruk, Gallagher, Hatzipanagos and Reynolds

(2018) comment that there is an increase in serious

games applied in health education, but the evidence

of its impact still isn’t very clear. For this reason, they

carried out a quick review study on serious games

concerning health and dental education, covering the

period from 2005 to 2016 and contemplating 10

repositories. Its purpose was to find evidence by

means of systematic reviews and meta-analyzes of the

impacts of serious games on health education and to

explore the impacts of serious games on dental

education. The result of the review found that serious

games are effective as a learning tool for improving

knowledge and skills and are an option for education

in health and dentistry. These games can be a

complementary strategy to involve students and

improve their motivation.

Morais, Vergara, Brito and Sampaio (2020)

conducted a study on integrative review to find works

on serious games aimed at education in children’s

oral hygiene, in addition to looking for apps on the

Android® platform available for this domain. The

author’s review used 8 repositories and Google

Scholar over the past 7 years. For the identification of

A Systematic Mapping of Serious Games for Oral Health

401

the applications, IEEE Xplore was used. As a result,

it was found that there are few apps for oral hygiene

education and most of them are aimed at children.

The authors claim that exploiting technological

resources (smartphones, tablets, notebooks, E-

readers) in this area can help in public health policies.

Mehrotra (2020) carried out a systematic review

in order to identify studies that address the inclusion

of entertainment in the dental curriculum through

animations and games. The review allowed to expose

the projects of educational tools designed, presenting

their advantages and limitations. It also analyzed the

students’ perception regarding the adoption of

unconventional techniques for teaching and learning

in the area. As a result, it was found that entertainment

tools such as games, animations, and mimicking

provide more fun learning.

As can be seen, the literature review studies in the

field of dentistry that covers serious games are related

to the identification of evidence of the use of games

in the area (Sipiyaruk et al., 2018), a specific audience

in the case of oral hygiene for children (Morais et al.,

2020) or to verify the inclusion of entertainment in

the dentistry curriculum (Mehrotra, 2020). Thus, the

review proposed in this article aims to answer the

following question: “What is the landscape of serious

games on Oral Health?”, in order to identify to which

audiences they target, which subjects are addressed,

what is the learning assessment process, among

others that are detailed in the next section.

4 METHODOLOGY

The method used to carry out the systematic mapping

was that of Kitchenham and Charters (2007). Studies

related to the focus of this research, in the period from

2015 to 2021, which approach learning games on oral

health, were identified. This period was defined to

relate the most recent studies in the area in question.

Figure 1 illustrates the process adopted.

4.1 Repositories and Search Criteria

The extraction of primary studies was performed in 4

(four) digital libraries (ACM, Scopus, IEEE Xplore

and SciELO). All searches in these repositories were

done covering the period between 2015 and 2021.

Several search terms had already been thought

and discussed among the researchers, which

facilitated the process of composing the search strings

and keywords. The keywords were: Game;

Education; Learning; Teaching; Oral; Dental.

Figure 1: Methodology overview.

The search string used was: TITLE-ABS-KEY

(game AND (education OR learning OR teaching)

AND (oral OR dental)).

4.2 Selection of Studies

The researchers who carried out the mapping were the

evaluators of the collected primary works. The

inclusion and exclusion criteria were then defined.

The inclusion criteria are:

• Articles written in English

• Open access articles

• Articles with relevance to the addressed topic

• Articles published from 2015

The exclusion criteria are listed below:

• Duplicate articles

• Conference papers

• Articles with title and abstract out of the scope

Selected articles must answer the following

research questions:

Q1. What subjects are covered in the games?

Which audience are they for?

Q2. How does the game work?

Q3. What technologies were used to build the

game?

Q4. How does learning assessment occur?

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Table 1 presents the preliminary results per

research database for the chosen string.

Table 1: Number of works per repository.

Repositories

ACM 2

Scopus 76

IEEE Xplore 10

SciELO 0

Total 88

From the search results, a selection procedure was

performed using the inclusion and exclusion criteria

for choosing the articles. Altogether, at the end of the

selection procedure, approximately 89.77% of the

included studies were eliminated by the exclusion

criteria. Figure 2 shows the result of the process of

executing the exclusion criteria.

Figure 2: Results of the sorting process.

5 RESULTS

From the criteria established for the search, and from

all sorting stages, the research resulted in 9 (nine)

articles. After a new analysis, three were excluded

because they were review articles (Sipiyaruk et al.

(2018); Morais et al. (2020); Mehrotra (2020)) in the

area. They were discussed in Section 3 of this paper.

Table 2 presents the selected studies and each was

identified with a unique number (ID).

Table 2: Selected articles.

ID Title Author (Year)

1 A 3D Serious Game for

Dental Learning in Higher

Education

Rodrígez-Andrés,

Juan, Mollá, and

Méndez-López

(2017)

2 ToothPIC: An Interactive

Application for Teaching

Oral Anatomy

Javaid, Ashrafi,

Žefran and

Steinberg (2016)

3 Development of web-based

dental health ladder snake

game for public elementary

school students in Indonesia

Rikawarastuti,

Ngatemi and

Yusro (2018)

4 Development and Evaluation

of a Mobile Oral Health

Application for Preschoolers

Campos et al.

(2019)

5 Using Augmented Reality to

Motivate Oral Hygiene

Practice in Children: Protocol

for the Development of a

Serious Game

Amantini et al.

(2020)

6 Gamification as a learning

strategy in a simulation of

dental anesthesia

Ribeiro, Corrêa

and Nunes (2017)

Below are the answers to each question.

5.1 Q1: What Subjects Are Covered in

the Games? Which Audience Are

They for?

Considering the selected studies, 2 serious games are

intended for students of higher education in dentistry

(Rodrigez-Andres et al. (2017); Javaid et al. (2016)),

2 for children (Campos et al. (2019); Amantini et al.

(2020)), 1 for dental professionals (Ribeiro et al.

(2017)) and 1 for elementary education

(Rikawarastuti et al. (2018)). The subjects covered in

the games are tooth morphology, tooth decay, among

others. Figure 3 shows the results for Q1.

Oral health issues such as: promotion, prevention

and control of oral diseases; guidance from groups

and people, among others, still need to be explored in

serious games in order to allow the individual to

obtain their oral health literacy. An individual who is

literate in oral health will have the ability to

understand the information and make the right

decisions. In turn, an individual with low literacy can

favor the occurrence of chronic diseases such as

periodontal diseases (Wehmeyer, Corwin,

Guthmiller, & Lee, 2011).

A Systematic Mapping of Serious Games for Oral Health

403

Figure 3: Answers to Q1.

5.2 Q2: How Does the Game Work?

Javaid et al. (2016) created a game where students can

remove a tooth (upper or lower) from a group of

randomized teeth, in a 3D virtual scene, and position

it in its location and correct orientation in the empty

arch, in addition to naming and numbering the

selected tooth. Once the student places the tooth in

what they think is the correct place, they can verify

the answer and proceed to the remaining teeth.

Rodrigez-Andres et al. (2017) developed a game

in which the individual can observe each tooth in

order to know its morphology. In the first phase,

through gestures, the student is able to approach and

rotate the teeth to analyze it. In the second phase, a

jaw is presented with holes for the student to fit the

correct teeth in their respective positions.

Ribeiro et al. (2017) created a game that uses

Virtual Reality (VR) techniques to simulate and get

closer to the reality of performing anesthetic

procedures through the reproduction of virtual tasks

necessary for learning. Gamification techniques were

applied to make the game more attractive, such as

scoring, difficulty levels, sounds, achievements, and

ranking. The game scenario takes place in a dental

office and a patient model in which it is necessary to

use a syringe, positioning it in the correct place to

perform the anesthetic procedure. The location of the

syringe insertion is represented by an object in the

shape of a sphere where the player can measure the

contact of the needle in the patient's gums for proper

application. When performing the procedure, the

player must use the mouse buttons to position the

syringe needle at an appropriate angle as well as its

depth, in addition to the keyboard to move the syringe

position in a Cartesian coordinate system. The angle

and depth have tolerance values, which are calculated

to indicate the player's successes and errors.

Rikawarastuti et al. (2018) created a game based on

Snakes and Ladders, whose goal is to be the first player

to reach the end, moving across the board, according to

the number that appears on the dice. Each “square” on

the board has an image referring to oral health. In

addition, there are stairs and snakes superimposed on

the squares. When a user falls into a square that

contains the base of the stairs, they are automatically

taken to the square at the opposite end, in the same

way, when the user falls into a square where they have

the head of the snake, they “slip” and are taken to the

square where the snake’s tail begins. In both cases, a

pop-up is presented with: i) an image of the initial

position; ii) an image of the player's final position after

the event, iii) a text relating the two images.

Campos et al. (2019) created a game for mobile

devices, available for Android and IOS, however, the

author did not describe the operation of the game,

emphasizing only the performance of users.

Amantini et al. (2020) created a game to teach the

brushing technique, which is available in the game for

children to perform the movement in a virtual

environment in order to stimulate oral hygiene and

proper brushing. The game is available on interactive

and immersive virtual panels and uses Kinect to

capture the movements of players and assess whether

the brushing was performed correctly.

Figure 4 illustrates the main objects used for the

operation of the games that were analyzed in this

article.

Figure 4: Main Object of Operation in the Game.

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It is noted that the main object/concept for 3 of the

studies was the tooth (Javaid et al. (2016); Rodrigez-

Andres et al. (2017); Amantini et al. (2020)), used so

that the student can learn to fit it in the correct place,

to number it, to identify its name, to practice brushing

and to understand its morphology. One of the studies

teaches the correct application of anesthesia using a

syringe (Ribeiro et al. (2017)) and the other study

uses images on a board to teach oral health

(Rikawarastuti et al. (2018)).

5.3 Q3: What Technologies Were Used

to Build the Game?

Considering the studies, 3 (Rodrígez-Andres et al.

(2017); Amantini et al. (2020); Ribeiro et al. (2017))

used the Microsoft Kinect device for motion

detection, along with the game development platform

Unity 3D and the C# programming language. In

addition, Ribeiro et al. (2017) used an

autostereoscopic display to improve the 3D

perception and the concepts of Natural User

Interfaces (INU), which allowed a greater level of

immersion in the game, controlled only by gestures.

Only 1 of the games was developed for the web

(Rikawarastuti et al. (2018)). The advantage in this

case is the possibility of games being multiplayer. In

1 of the studies the authors (Campos et al. (2019))

developed an app for mobile devices, however, it was

not clear what technologies were used, only that it

was developed for Android and iOS. Finally, 1 article

(Javaid et al. (2016)) used Python programming

language with the Numpy library and the H3DAPI

development platform to deal with 3D graphics.

Table 3 shows the results for Q3.

Table 3: Answers to Q3.

ID Technologies

1 Natural user interfaces (NUI); Autostereoscopic

display; Microsoft Kinect; Unity 3D platform / C#

language.

2 Python programming language; NumPy library;

H3DAPI platform.

3 Apache2 server; PHP programming language;

JavaScript programming language; MySQL

database; CodeIgniter 3 framework.

4 Did not explain the technologies used.

5 Microsoft Kinect; Unity 3D platform/ C#

language.

6 Blender 3D; Microsoft Kinect; Unity 3D platform/

C# language.

It is noted that most games were developed in

three-dimensional environments with the Unity 3D

platform and the Microsoft Kinect device; this is due

to the inccreasing popularization and accessibility to

such technologies and devices. It was also found that

the games have mainly, simulation environments.

5.4 Q4: How Does Learning

Assessment Occur?

For this question, it was identified the way the game

was evaluated by the user. Only one of the studies

(Rodrigez-Andres et al. (2017)), refer a comparison

between learning before and after its execution,

through the application of questionnaires that

measured the difference in learning. In addition, an

opinion and progression questionnaire was used

during the game.

The evaluation method of the other games was

based on performances obtained during the execution

of the games (real-time feedback, scoring, and

progression). For these, users’ opinion questionnaires

were applied concerning the game, except in one of

the studies (Rikawarastuti et al. (2018)) that did not

collect any feedback. Table 4 shows the results for

Q4.

Table 4: Answers to Q4.

ID Assessment Process

1 Game progression; Before and after questionnaire

and comparison; Users’ feedback.

2 Game progression; Users’ feedback.

3 Game progression.

4 Game progression; Users’ feedback.

5 Game progression; Users’ feedback.

Game progression; Users’ feedback.

It is noted that, from the analysis of the studies, it

is necessary the development of research that evaluate

the effective contribution of the users' learning from

the games.

6 DISCUSSION

This study found that in the literature there is the need

for the creation of interactive and reliable tools to

assist and evaluate functional and conceptual literacy

in oral health, corroborating the finding made in the

work of Martins et al. (2015).

Serious games are an alternative that can be

adopted for education in oral health, which promotes

the literacy of the individual. Serious games,

according to Mello and Zendron (2015), promote

cognitive skills in which individuals learn in an

interactive and attractive way. In this way, serious

games in oral health can be used as an instrument to

A Systematic Mapping of Serious Games for Oral Health

405

assist in the prevention and control of oral diseases

reaching various audiences, among them those who

have serious mental issues.

Assessment is an important element in any

knowledge development process. Therefore,

pedagogical criteria are necessary in order to obtain a

good learning response. Araújo et al. (2013) explains

that Bloom’s Taxonomy is an instrument that

supports the identification of a hierarchical structure

with well-defined objectives, supported by cognitive

domain categories, which help in the elaboration of

questions for the assessment and perception of the

acquired skills and knowledge. Thus, it was found

that the selected studies need a knowledge-building

process that implements assessment methods.

Another aspect that was observed is the lack of

techniques to keep the user motivated and engaged

during the game. Reis, Oliveira, and Pio (2017)

explain that the level of interest of the student in

learning can affect their academic life, and propose

the use of a motivation model called ARCS

(Attention, Relevance, Confidence and Satisfaction)

for the automatic adjustment of the level of difficulty

of a game using an Artificial Neural Network (ANN)

algorithm. In this way, it is possible to keep players

more engaged and consequently the level of success

of the game is achieved.

7 CONCLUSION

This article presented a systematic mapping to

identify serious games for learning about oral health.

These games can promote oral health education and

consequently assist in the individual's literacy in oral

health.

During the analysis of the selected studies, it was

found that the target audience are undergraduate

students in Dentistry, professionals in the field, and

children. The subjects covered are directed to oral

hygiene, morphology and anesthesia.

Some technologies used for game development

are Unity 3D and Microsoft Kinect. Machado (2014)

justifies the use of Kinect because it is a low-cost

device and very efficient in recognizing movements,

in addition, the equipment developer (Microsoft)

provides a development kit to be used in third-party

software. Carvalho (2012), on the other hand,

explains that the great advantage of using Unity is the

fact that it is multiplatform, with games developed for

desktops, mobile, and web changing simple

configurations. In relation to learning assessment, it

was observed that there is a way to measure through

questionnaires; however, the use of learning

assessment methods needs to be explored.

Another finding is that the games do not include

Artificial Intelligence techniques, which could make

them offer an individualized learning environment

and greater motivation.

The serious games presented in the oral health

domain have simulation characteristics. The use of

entertainment elements can make them more

attractive, allowing greater interaction and motivation

by the user during their learning.

As future work, it is suggested to explore methods

of learning assessment and domains of oral health in

order to propose a game in oral health that allows the

individual they literacy.

ACKNOWLEDGMENTS

This work has been supported by FCT Fundação para

a Ciência e Tecnologia within the Project Scope:

UIDB/05757/2020.

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