Use of virtual simulation for regenerative endodontic training: randomized controlled trial

Abstract

Objectives

This study aimed to develop an experimental teaching module based on virtual simulation (VS) to facilitate the instruction of undergraduates in regenerative endodontic procedures (REPs) and to assess its impact on academic outcomes and students’ perceptions.

Methods

A REPs-VS platform with detailed diagnostic thinking, treatment protocol, and outcome evaluation scripts we developed. In total, 123 undergraduates in the fourth year were randomly divided into group A (REPs-VS teaching mode) and group B (traditional teaching mode). The effectiveness was evaluated by theoretical and operational examinations. The perspectives of students were assessed via questionnaires.

Results

The total scores of the theoretical and operational examinations in group A were 82.10 ± 14.50 and 90.65 ± 4.81, respectively, which were significantly higher than the control group. Approximately 98.3% of students in group A agreed that the REPs-VS teaching platform improved their knowledge and skills. Most of the students in both groups unanimously acknowledged that the REPs-VS platform effectively enhanced the course’s entertainment value and consequently increased their enthusiasm.

Conclusion

The REPs-VS teaching platform established herein is an innovative and practical tool that can enhance the comprehension of REPs among undergraduate students, providing a more robust foundation for clinical practice.

Introduction

Regenerative Endodontic Procedures (REPs) utilize tissue engineering principles to promote ongoing root formation and functional regeneration. This approach is widely regarded as the optimal treatment option for young permanent teeth with pulp necrosis [1]. The procedures include provoking bleeding from the periapical tissue into the sterilized root canal to form blood clots containing growth factors and stem cells, which may facilitate regeneration. Nevertheless, this procedure is complex and challenging to execute. Preclinical education builds a bridge between theory and practice. An assessment of the attitudes of dental residents indicates that a majority believe REPs should be incorporated into undergraduate dental education [2]. However, experimental teaching in REPs is not widely implemented. In undergraduate education in Saudi Arabia, only two dental schools offer preclinical training for regeneration [3]. This is due to the difficulty of simulating the treatment processes of preservation or regeneration using artificial acrylic typodonts or extracted teeth, despite the development of some models that have not yet been widely adopted [4]. Consequently, traditional teaching for REPs relies mainly on theoretical learning and clinical observation [5]. Minimal time was dedicated to REPs in modern endodontic curricula [6,7,8].

Recent technological and computational advances have led to the development of alternative teaching modalities better suited to conveying these techniques to endodontic students. Virtual simulation (VS) technology is a novel teaching method that utilizes computer systems to construct highly realistic virtual experimental environments and objects [9]. The types and devices of VS used in dental education are diverse, including virtual reality simulations (VR), augmented reality (AR), haptic simulators, virtual mobile platforms, and serious games. VR enables students to interact with virtual patients without causing any harm to real patients or facing ethical issues. This interaction reduces anxiety associated with managing real patients during the learning experience [10, 11]. Learners can also practice at their own pace, repeating certain learning modules to reinforce specific abilities as needed. Such modules have been documented to improve teaching quality through the way of intuition, repetition, and objective assessment [12]. AR, on the other hand, integrates the virtual with the real, allowing students to visualize complex spatial relationships and abstract concepts. For example, it aids in the training of procedures like block anesthesia of inferior alveolar nerve [13]. Haptic simulation employs a highly precise tactile feedback system to replicate various sensations experienced during dental procedures, such as the vibrations during drilling, the complex structures within root canals, and the resistance felt during manipulations, as well as the varying hardness of materials or tissues. Research suggests that this technology can enhance students’ cavity preparation skills and accelerate the learning curve [14]. Unlike most VS that require laboratory conditions, virtual mobile platforms are not constrained by time and space limitations, allowing for the operation of virtual applications on personal computers and mobile phones [15]. Simulation-based serious games represent an effective and scalable teaching strategy. It can simulate skill training [16], case analysis [17], oral health management [18], and provide interactive and motivational learning experiences that boost students’ enthusiasm for learning. Multiplayer collaborative modes also encourage teamwork. Serious games typically come with an assessment system that provides immediate feedback on whether students’ actions or decisions are correct, helping them correct mistakes promptly. This instant feedback mechanism aids students in learning more rapidly [19]. For instance, an interactive software specifically designed for training in pulp and periapical diagnosis is considered to be both effective and efficient, demonstrating significant potential in teaching and assessing learners’ diagnostic skills [20].

VS is commonly utilized in various dental fields, including conservative dentistry, surgery, prosthodontics, implantology, and occasionally in pediatric dentistry, radiology, periodontics, endodontics, and orthodontics. According to the limited studies on the application of VS in endodontic education, VS is primarily used in cavity preparation [21,22,23], apical surgery [24], apexification [25], endodontic diagnosis [20], and root canal anatomy [26, 27]. These studies on virtual reality, haptic feedback, and software interaction demonstrated that VS yielded significantly better outcomes. Even with brief training durations, VS significantly enhanced the acquisition of manual skills and provided a slight boost to the retention of theoretical knowledge [28]. Screen-based interactive simulations are a key element of virtual simulation (VS), offering a cost-effective training solution through mobile and tablet capacitive screens. These tools enhance learning, collect data, and provide feedback to both trainees and instructors, bridging virtual and physical simulations [29]. For instance, a Virtual Oral Medicine Clinic (VOMC) has been utilized to assist undergraduate students in the identification of oral lesions [30]. Similarly, Al-Madi et al. have developed specialized endodontic training software, highlighting the significant potential of interactive tools in enhancing dental education [20]. More recently, the development of a VS training tool for vital pulp therapy has filled a gap in experimental teaching for vital pulp preservation [31]. Currently, REPs lack effective experimental teaching methods, leaving students in a passive learning state. Therefore, it is necessary to incorporate new technologies and methods to promote their application in dental practice [2].

We independently designed a VS experimental platform enabling students to simulate the REPs procedure in an interactive manner, addressing the challenges in traditional teaching, and contributing to the integration of new clinical technologies into an undergraduate experimental teaching curriculum. Moreover, we investigated whether the application of the REPs-VS platform can improve their theoretical and operational capabilities, enhance their communication skills, and hence achieve a level of self-confidence and competence.

Methods

REPs-VS teaching model development

The REPs model in this study involved the collaborative use of various technologies and software, including Unity3D, Visual Studio, ARKit, DirectX, and Figma. Through 3D simulation, animation technology, graphics rendering, and user interface design, the platform achieves precision in experiments, aesthetic visuals, and smooth interactivity. Multi-platform support and real-time interaction further enhance the user experience, enabling the platform to operate efficiently across different devices. Users were able to interact with a virtual patient and perform specific operative procedures through a web-based interface by clicking. The Virtual Simulation Experimental Teaching Center of Stomatology designed the detailed and refined REPs experimental script used herein. This teaching module focused on a patient who had chronic periapical periodontitis and an immature incisor. The treatment protocol was designed based upon the revised 2021 Clinical Considerations for a Regenerative Procedure by the American Association of Endodontics.

Digital platform

This module was designed to be compatible with mainstream operating systems including Windows, Android, iOS, and can be deployed in the form of web pages, standalone executable files, or Apps for use on various devices. Users were thus able to learn and ‘practice’ without any limitations of time or space. To meet global educational needs, a network version of the resource is also accessible on the National Virtual Simulation Experiment Teaching Center (iLAB-X) (https://www.ilab-x.com/details/page?id=37&isView=true). This platform functions as an effective national virtual simulation experiment integration platform [32]. Off-campus learners are free to utilize the platform for educational purposes or integrate it into their teaching activities, similar to the platform developed by Sun Yat-sen University [31]. However, the management system for virtual experiment projects is hosted on the university’s internal servers. The development and operation of this management platform rely on the Eclipse development environment and the MySQL database for support.

An educational administration platform is a vital component of our VS teaching module. This platform incorporates an intelligent attendance system, an educational administration system, a problem communication system, and a VS practicing and examination system. This study utilized the platform to allow students to select a course, learn at a self-determined pace, complete the VS examination, and engage with their teachers in an online setting.

Sample size calculation

The effect size (Cohen’s d) at 0.34 with a significance level set at 0.05 and a statistical power of 0.95 was estimated based on the existing research [31]. G*Power software (version 3.1.9.7) was used to perform the analysis that a sample size of 102 students is necessary. Considering a potential 10% dropout rate, a sample size of 123 students was finally concluded.

Implementation and assessment

A total of 123 fourth-year undergraduates majoring in stomatology participated in this study (Fig. 1). The study received ethical clearance from the Medical University Ethics Committee in 2022 (No: 202241). The students were randomly divided into an experimental group (Group A) and a control group (Group B), with 62 students in Group A and 61 students in Group B, respectively. This allocation was achieved by inputting the student ID numbers into a random group generator and using a calculator to randomly divide them into two groups. Both groups attended a didactic lecture on REPs lasted for two teaching hours. Then a theory exam was designed to compare the level of knowledge in baseline. The result was recorded as Score One. The theoretical assessment is divided into two parts: communication and clinical decision-making (Dimension 1), and operational skills (Dimension 2). The theoretical exam is based on the “Medical Education Question Bank,” which can be accessed at http://tk.ipmph.com.

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Then online resources including operation videos and detailed guidelines were provided to Group B. These resources were available at the following links: https://coursehome.zhihuishu.com/courseHome/1000081773#teachTeam. While students in Group A were requested to perform the VS course on the virtual simulation platform, including interviewing, decision making and the interactive virtual operation in their own time. The efficacy of learning could be self-tested through the examination mode. Both groups of students were able to send inquiries to their teachers or peers via the internet platform.

One week later, both groups completed the theory and operation examination and the results were recorded as Score Two and Score Three, respectively. The operation model used in the operative exam was made according to the previous literature [4]. The score was based on apparatus selection (Dimension 3), operation steps (Dimension 4), and doctor-patient communication (Dimension 5). The scoring criteria were specifically aligned with the clinical considerations for REPs as revised by the American Association of Endodontists in 2021, which are detailed in the supplementary materials.

Student perceptions were assessed using a 12-item five-point Likert scale questionnaire, with each item being rated from 1 (strongly disagree) to 5 (strongly agree). Questionnaire A focused on: (1) knowledge and skills, (2) learning experience, and (3) attitude change towards this teaching modality. Questionnaire B included (4) the advantages of VS, and (5) any additional comments or questions. Following the assessment, group A completed the two questionnaires, while group B only completed questionnaire (A) After the research, students in group B received the same VS course as a supplement teaching and completed questionnaire (B) The mobile app SurveyStar was used to collect questionnaire data, and the Cronbach’s alpha values were calculated.

Statistical analysis

The exam scores are expressed as means ± standard deviations (SD). Differences in scores between groups were evaluated by t-test. The questionnaire scores of the two groups were assessed using Fisher’s exact test. SPSS (version 26; IBM) was used to analyze the data and p < 0.05 was considered to indicate statistical significance.

Results

REPs-VS teaching module functionality

The REPs-VS platform could be entered from the national virtual simulation experiment space, providing two modes including learning and examination. In the learning mode, the network simulates a community where students establish an oral clinic. The virtual patient is a young individual with dental trauma and periapical periodontitis. Students could practice the basics of clinical reasoning including symptom recognition, diagnosis, and treatment planning through simulated doctor-patient communication (Fig. 2a-c). In addition, the simulation included the patient’s oral environment, equipment selection, and operational procedures, providing visual feedback through high-precision graphics and animations. Students engaged in repetitive practice of the steps of the REPs to enhance their understanding of the experimental principles and operative steps (Fig. 2d-e). The REPs-VS platform then presented animated treatment outcomes including continued root development, enabling students to master the criteria for evaluating treatment efficacy (Fig. 2f). Furthermore, the model introduces game elements in the examination mode, where students earn corresponding diagnostic and treatment coins while making clinical decisions and performing simulated surgeries. The number of coins determines their position on the leaderboard.

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Analysis of theoretical and operational examinations

The efficacy of the REPs-VS teaching methodology was assessed by theoretical and practical exams. The first test was taken after the didactic lecture (Score One), and the scores were comparable between the two groups in decision-making (Dimension 1) and operative procedures (Dimension 2), indicating the same baseline level for the two groups (p = 0.771) (Table 1).

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According to Table 2, the total score of the theory exam (Score Two) in group A after REPs-VS learning was 82.10 ± 14.50, which was significantly higher than the control group (p = 0.000). In the clinical decision and operation process, the scores were higher than the control group, and the difference was statistically significant (p = 0.003, p = 0.006). In terms of the operation exam, the total score of group A was 90.65 ± 4.81, which was significantly higher than that of the control group (p = 0.000). Specifically, the score for the operational steps (Dimension 4) was 54.87 ± 3.16, which was considerably higher than the control group (p = 0.000). The scores were comparable between the two groups in apparatus selection (Dimension 3) and doctor-patient communication (Dimension 5) (p = 0.105, p = 0.052). Table 3 further exhibited the changes between Score One and Score Two for group A. The results showed that the REPs-VS platform considerably improved the theoretical scores (p = 0.000).

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Students’ perceptions

The questionnaire responses were categorized into five broad groups to more effectively capture the primary features of REPs-VS. The Cronbach’s alpha values for this questionnaire in Group A exceed 0.7, and the Spearman’s rank correlation value is close to 1, indicating that the questionnaire exhibits strong internal consistency and effectively measures students’ perceptions (Table 4) (Figs. 3 and 4).

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Knowledge and skills

In group A, 98.3% of students concurred that the REPs-VS teaching platform enhanced their understanding by providing an emulation of the operational requirements and learning needs. The average score of the questionnaire was 4.38 ± 0.80, which was markedly higher than group B (p = 0.008). 98.4% of students agreed that their clinical reasoning, knowledge, and decision-making skills have been improved with an average score of 4.20 ± 0.88. In addition, 98.3% of students agreed that the platform improved their doctor-patient communication abilities and humanistic literacy (score = 4.13 ± 0.81).

Learning experience

Theoretical and experimental results regarding student academic performance were presented in Tables 2 and 3. 98.4% of students in group A were satisfied with their final learning performance with an average score of 4.26 ± 0.82, which was significantly higher than the control group (p = 0.049). The educational design was deemed acceptable by both groups (p = 0.607).

Attitude change

The self-evaluation results indicated that the REPs-VS platform transitioned from being a passive teaching tool to an active learning application. This transition was facilitated by the ease of access and the repeated practice opportunities. As a result, students’ confidence improved and the stress associated with performing this operation in future patient encounters was reduced. The scores including three items were significantly different between group A and group B, respectively (p = 0.018, p = 0.001, p = 0.000).

The advantages of the REPs-VS platform

Most students in both groups concurred that the REPs-VS platform overcame the temporal and spatial limitations of traditional experimental learning. Additionally, the platform enhanced the course’s entertainment value, leading to increased enthusiasm among the students. This platform also provided a better view of the clinical scenario and improved the safety of operation.

Other comments

Many students offered feedback and recommendations for enhancing the REPs-VS platform (Fig. 5). They hoped that more realistic image of the character and more detailed and interactive experiments should be designed to make the simulated clinical situations more realistic and abundant.

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Discussion

Preclinical training is crucial for dental students to gain adequate knowledge and dexterity in specific operative procedures [33]. Limitations to effective instruction, however, include an inadequate faculty-to-student ratio, particularly for laboratory courses, as well as a lack of appropriate teaching aids and facilities necessary to ensure uniform training, and a lack of the necessary time and teeth to ensure that preclinical practice can facilitate clinical skill proficiency [34]. In addition, some students get excessively preoccupied with their academic grades and as a result, neglect to fully engage in the discussion and evaluation of experimental processes and findings. Moreover, many undergraduate dental students suffer from high levels of stress due to their workloads, tests, and clinical care obligations [35].

This study aimed to develop a VS experimental teaching platform to help instruct undergraduates in the REPs procedure, and to incorporate this module into their curriculum to evaluate its effect on their academic performance and perceptions. The students learning via REPs-VS teaching mode had better scores in the theoretical and operational exams than those learning via traditional didactic lectures. Studies have shown that VS platforms can increase knowledge retention and skill acquisition [36, 37]. VS may enhance the acquisition, retention, and transfer of knowledge in REPs education for several reasons:

1. (1)

Enhanced memory and comprehension: This platform presents medical theories and operative protocols in a vivid 3D computer-generated environment, offering an interactive learning experience that can help students better understand and internalize complex dental concepts and procedures [10]. A study revealed that a virtual 3D simulation–based progressive digital training module can enhance knowledge retention in removable partial denture design even one year later [38].

2. (2)

Improved skill transfer: VS not only aids students in mastering theoretical knowledge but also enhances their ability to apply this knowledge to practical operations. Research indicates that the combination of virtual patient training and didactic instruction can improve the knowledge transfer of oral surgery students [39, 40].

3. (3)

Real-time feedback: Through self-study and self-assessment modes, students can evaluate their performance and identify areas for improvement. Additionally, the platform records students’ study hours, progress, and mastery of the materials, which aids teachers in providing targeted guidance. This immediate feedback mechanism has been proven to significantly enhance learning outcomes [41].

4. (4)

Reproducibility: The virtual mobile platform allows students to repeat practice without time and space constraints until they master the relevant skills and knowledge. Based on experiential learning theory, students acquire knowledge and experience through virtual mobile platforms, reflect upon them to form concepts, and apply these concepts in future clinical practice. This cyclical learning process aids in deepening and expanding knowledge and skills [42]. This aligns with findings from a randomized controlled study on using VS for teaching tendon repair surgery [43]. While the long-term practical significance of VS in dental education is not yet fully understood, the REPs-VS platform serves as a positive supplement to traditional lecture-based teaching in the field of REPs, where practical teaching models are lacking.

According to the questionnaires provided to the participants, 91.8-98.4% of them believed that this interactive learning platform offered a low-stress and low-risk environment. Dental surgery can be a frightening and anxiety-inducing process for beginners. VS provides a risk-free environment where students can learn and practice without pressure. Additionally, the VS platform immerses students in an environment with audiovisual feedback, creating a more tangible experience. Potential applications of similar platform include pre-admission assessments, pre-clinical training, remedial training, and external certification for licensing [44]. The experimental results also showed that the VS group had stronger learning motivation compared to the traditional teaching group. This could be partly due to the interactive and engaging nature of the model, which stimulates students’ interest in learning. For example, study found that students using VR for dental surgery and orthodontic training showed higher engagement and satisfaction [45]. Another factor is the introduction of gamification elements in the virtual scenarios. The platform simulates an online community where students create dental clinics and apply REPs knowledge to treat a virtual patient, earning corresponding diagnostic and treatment coins (grades), with the number of coins determining their position on the leaderboard (ranking). Studies have shown that gamification elements, such as points, leaderboards, and reward mechanisms, can stimulate students’ competitive spirit and sense of achievement, thereby enhancing their learning motivation.

The VS teaching platform developed in this study, while demonstrating significant potential as an innovative educational tool for accelerating students’ clinical skill acquisition, necessitates further refinement to address several critical limitations inherent in its current implementation [46]. The VS platform integrates a virtual mobile interface with gamification elements. Due to the lack of haptic feedback, students are unable to experience the differences in hardness between enamel and dentin, as well as the interferences from soft tissues, saliva, and patient movements [41]. The absence of physical sensation may also limit learners’ precise control over force, pressure, and touch, which are essential components of psychomotor skills. From a technological perspective, while VS technology represents a promising advancement in dental education, its widespread implementation is constrained by substantial financial and technical barriers. The development and maintenance of a robust VS platform entail significant investment in high-performance computing infrastructure, advanced graphics processing capabilities, and comprehensive data storage and transmission systems. These technical requirements, coupled with ongoing costs for software development, system maintenance, and periodic upgrades, present considerable challenges for institutional adoption. The current study’s methodological limitations warrant careful consideration. The relatively short observation period precludes definitive conclusions regarding the long-term retention of acquired knowledge and skills. Future research should incorporate longitudinal studies to evaluate students’ sustained mastery of REPs, their subsequent clinical performance in professional practice, and ultimately, the treatment outcomes of patients managed using these techniques. Additionally, the study’s scope was limited to senior dental students, excluding interns, thus necessitating further investigation into the platform’s efficacy during the critical internship phase. Other notable limitations include the single-center recruitment strategy, the homogeneity of clinical scenarios presented, and the insufficient exploration of faculty perspectives. It is worth noting that continuous training under the supervision and feedback of teachers remains a key expectation for good dental education [15]. Teachers are essential as role models in guiding students to develop empathy and solve complex clinical problems.

Given these challenges, we propose the following prospects for its future development:

1. (1)

Simulation-based serious games: By leveraging the internet, serious games can facilitate global student collaboration and knowledge sharing, thereby promoting international exchanges in dental education. The introduction of a competitive game mode would likely enhance student motivation and factual knowledge [47].

2. (2)

Integration and Utilization of Artificial Intelligence Technology: Enhance the efficiency and effectiveness of dental education through personalized learning paths, virtual assistants and mentors, simulation and practical training, and data analysis and evaluation [48].

3. (3)

Mixed Learning Mode: Utilize the simulation advantages of virtual reality while combining practical tactile experiences and complex scenarios to comprehensively improve students’ psychomotor skills and clinical decision-making abilities. Simultaneously, integrate teachers’ guidance with virtual reality technology to maximize the teaching effect [34].

4. (4)

Technical optimization and sustainable development: Investigate methods to enhance the technical architecture of the VS platform to reduce implementation costs. Concurrently, explore strategies for the recycling and repurposing of hardware equipment, encourage the sharing and open-sourcing of software resources, and ultimately achieve the sustainable development of the virtual simulation platform.

In conclusion, the REPs-VS platform developed herein was a novel and practical tool for preclinical education, enabling undergraduates to improve their clinical reasoning and operative experience related to this operation. This platform offers several benefits, such as an enhanced interactive and immersive environment, the elimination of temporal and spatial constraints on learning, and improved teacher-student communication, highlighting its potential future utility.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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