Influence of virtual reality simulation (excluding augmented reality) on endodontic learning experiences of undergraduate dental students: a systematic review

Abstract

Section Background

Virtual Reality (VR) technology has demonstrated a promising prospect for enhancing endodontic learning in undergraduate dental students by boosting their procedural skills, accuracy, and confidence.

AbstractSection Aim

To systematically evaluate the effectiveness of virtual reality (VR) simulation in endodontic education among undergraduate dental students, with a specific focus on four key outcomes: procedural accuracy, enhancement of student confidence, reduction in procedural errors, and overall learner satisfaction.

AbstractSection Methods

An exhaustive literature search was carried out in December 2024 in PubMed, Cochrane Library, Embase, Scopus, and ClinicalTrials.gov. Randomized controlled trials (RCTs), quasi-experimental studies, and cross-sectional studies published between 2010 and 2024 were included in the review. Risk of bias was appraised as follows: Cochrane Risk of Bias 2.0 (RoB2) tool for RCTs; Newcastle-Ottawa Quality Assessment Scale adapted for cross-sectional studies; National Institute of Health (NIH) Quality Assessment Tool for before-and-after studies; and the Methodological Index for Non-Randomized Studies (MINORS) tool for non-randomized studies without a comparator group.

AbstractSection Results

Fifteen studies were included in the final analysis. VR-based training showed statistically significant differences between the pre and post-test scores regarding procedural accuracy and efficiency for tasks at the end of endodontics. These results showed that VR training leads to greater confidence and skill levels in students than traditional approaches, improved retention of knowledge, and a reduction in errors. Advantages notwithstanding, limitations around cost and accessibility were observed.

AbstractSection Conclusion

VR simulation is an effective, valuable tool in the endodontic education toolbox. Further studies should assess cost-effectiveness and long-term clinical performance effects.

Introduction

The Virtual Reality (VR) technology is emerging as a revolutionary tool in oral health education where simulated environments exist for students to practice complex procedures. By using gamified interactive training, syringe simulations in VR can also allow students to work on their motor skills, and accuracy for procedures, and get real-time feedback on their practice. Simulation-based learning has been recognized as an effective mechanism in dental education that provides students with a controlled environment to practice skills they would otherwise need to perform on patients, with the ethical and practical challenges that entail [1].

Virtual Reality (VR) and Augmented Reality (AR) are often collectively discussed in educational simulation contexts; however, they represent distinct technologies. VR refers to an entirely immersive digital environment where the user interacts with a simulated world, often using headsets and hand controllers. In contrast, AR overlays digital information onto the physical world, typically using smart glasses or mobile devices. While both have educational value, this review primarily focuses on studies that utilized VR, where learners are immersed in simulated environments for endodontic training.

VR in endodontic training has brought significant advantages to current teaching methods. VR simulations help students better simulate the performance of actual endodontic procedures with more accuracy and less anxiety [2]. Interactive simulators and virtual realistic environments promote greater depth of engagement and provide students with the time needed for effective learning, with the advantage of immediate feedback [3]. The slightest improvement of technical skills, such as the repeatability of preparing access cavities and performing root canal treatments, is a vital aspect of endodontic education and performance.

It is noteworthy that the complete deployment of VR in dental education is facing multiple challenges such as huge implementation costs, infrastructural needs, and training of faculty [4]. A prior systematic review identified that VR could optimize educational performance however disparities in access and tech limitations do raise concern [5]. Studies have concluded that VR training significantly improves learning outcomes across dental education, but further research is needed to identify any long-term impact on clinical performance or cost-effectiveness [6]. The objective of this systematic review is to compile previous evidence concerning the impact of VR simulation on endodontic learning in undergraduate dental students.

Methods

Protocol and registration

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines and was registered in PROSPERO (International Prospective Register of Systematic Reviews) under the registration number - CRD42024622591 [7].

Inclusion and exclusion criteria

A set of inclusion and exclusion criteria was established to ensure relevant studies were selected. Studies involving undergraduate dental students trained using Virtual Reality (VR), with or without Haptic Technology (HT), were included. Studies focusing exclusively on Augmented Reality (AR) were excluded unless AR was integrated as part of a broader VR-based training simulation. Outcomes assessed included procedural accuracy, efficiency, confidence, error reduction, and satisfaction. The review included randomized controlled trials (RCTs), non-randomized studies, quasi-experimental studies, systematic reviews, and observational studies published between 2010 and 2024. Studies unrelated to VR in endodontics, without full-text availability, or categorized as case reports, expert opinions, and conference abstracts were excluded.

Information sources

A comprehensive literature search, unrestricted by language, was conducted utilizing electronic databases, including PubMed, Cochrane Library Central, and Google Scholar in December 2024. Additional search methods comprised reviewing reference lists of included articles, exploring the Clinical Trials Registry-India (CTRI), and manually searching relevant journals. The literature search was performed by two independent reviewers namely MQJ and BA. Both forward and backward citation searches were employed to enhance comprehensiveness [8].

Search strategy

The search strategy was structured based on medical subject headings (MeSH) and text words aligning with the PIOST framework that corresponded to population, intervention, outcome, study design, and time period respectively. Keywords and related terms were chosen based on authors’ knowledge, current literature, and indexed databases. The search strategy was developed using boolean operators such as ‘OR’ and ‘AND’ which were adjusted for each database (Table 1).

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Screening process

Two independent reviewers conducted the screening process by first evaluating titles and abstracts using Zotero reference management software. Full-text reviews were then performed to assess eligibility. Disagreements between reviewers were resolved through discussion with a third reviewer. No automation tool was used in the selection process.

Data extraction

Data extraction was performed by two reviewers using a standardized template to ensure uniformity. Extracted data included study details (author, year, country), study characteristics (design, intervention type, duration), participant characteristics (sample size, education level), intervention details (type of VR system used, level of interactivity), outcome measures (accuracy, confidence, knowledge retention, satisfaction), and study results.

Risk of Bias assessment

Two reviewers independently assessed the methodological quality of each study according to its respective study design. The Newcastle-Ottawa Quality Assessment Scale, adapted for cross-sectional studies, was used for three studies. This scale evaluates the quality of studies using a star-based system wherein each study is assessed in three categories: selection of study groups, comparability of groups, and the ascertainment of either the exposure of interest in case-control studies or the outcome of interest in cohort studies. Studies of good quality receive a minimum of six stars. The 12-item National Institute of Health (NIH) Quality Assessment Tool for before-and-after studies was used for two studies that lacked a control group. The NIH checklist evaluates the internal validity of a study. Scoring for this tool was as follows: 0–3 indicated a low risk of bias, 4–8 indicated a moderate risk, and 9–11 indicated a high risk of bias.

For non-randomized studies without a comparator group, the Methodological Index for Non-Randomized Studies (MINORS) tool was used, with an ideal global score of 16 for non-comparative studies. Four studies were assessed using the MINORS tool. In this review, a score of 8 or below was considered poor quality, 9–14 moderate quality, and 15–16 good quality, in accordance with previous reviews. Five randomized controlled trials (RCTs) were assessed using the Cochrane Risk-of-Bias Tool for Randomized Trials (RoB2), which evaluates five bias-related domains: randomization, deviations from intended interventions, missing outcome data, outcome measurement, and reported results. Studies were categorized as having a ‘low,’ ‘some concerns,’ or ‘high’ risk of bias. Additionally, the revised Cochrane Risk-of-Bias Tool for randomized crossover trials was used for one study.

Data synthesis

Due to the heterogeneity of included studies, a narrative synthesis was performed rather than a meta-analysis. Findings were grouped based on key outcomes, including procedural accuracy, confidence levels, and satisfaction with VR-based training. Data were further categorized and summarized in tables to facilitate a clearer comparison across studies.

Results

Study selection

A total of 741 studies were initially identified through database searches. After removing 42 duplicate records, 699 studies remained for the title and abstract screening. Following this initial screening, 662 studies were excluded based on relevance to the research question, leaving 37 full-text articles for further assessment. These articles were reviewed in depth based on the inclusion and exclusion criteria. After a thorough evaluation, 22 studies were excluded due to reasons such as lack of virtual simulation component, study population mismatch, or different study design. The final review included 15 studies that met all eligibility criteria. The complete selection process is illustrated in Fig. 1. All the reasons for exclusion are outlined in Table 2.

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Study characteristics

The included studies featured a range of sample sizes, from 20 to 200 students, and were conducted in different geographical regions. Among the included studies, five were randomized controlled trials [6, 19, 31,32,33], one study followed a cross-over trial design [34], three cross-sectional studies [35,36,37], two single group pre-post studies [38, 39] and four non-randomized studies without a comparator group [40,41,42,43]. The VR interventions assessed in these studies included haptic-based simulators, immersive VR platforms, and augmented reality applications designed to improve endodontic training. The duration of VR-based training programs varied from single-session interventions to multi-week training modules integrated into dental curricula.

Study characteristics extracted included the type of VR system used, its level of interactivity, and the outcomes measured. The primary outcomes assessed across studies included procedural accuracy, efficiency, confidence levels, error reduction, and student satisfaction. The data extraction process focused on identifying trends across studies regarding the effectiveness of VR compared to conventional learning methods.

Several studies incorporated real-time feedback mechanisms within VR platforms, enabling students to correct their errors during practice. Studies also evaluated the long-term retention of knowledge and practical skills, with follow-up assessments conducted weeks or months after the intervention. The detailed characteristics of each study, including study design, participant demographics, and key findings, are presented in Table 3.

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Risk of Bias assessment

All three cross-sectional studies assessed using the Newcastle-Ottawa Quality Assessment scale received five stars or below. One study was of moderate quality [37], while the other two received fewer than three stars, indicating poor quality [35, 36]. All three studies employed convenience sampling, and none justified their sample sizes (Table 4). Table 5 presents the NIH Quality Assessment Tool for before-and-after studies with no control group. The two studies were judged to have a moderate risk of bias [6, 38]. Neither study reported whether all eligible participants were enrolled, whether they were truly representative, or provided a rationale for the sample size. According to the MINORS scoring scale, three studies were of poor methodological quality, while one study was of moderate quality. Blinding was not performed in two studies, while loss to follow-up was reported in only one study. Only one study provided information regarding sample size. (Table 6) Based on the RoB2 assessment, two studies showed an overall high risk of bias [31, 32], while two studies had some concerns [6, 19]. Only one study demonstrated an overall low risk of bias [33](Fig. 2). The RoB2 assessment for the crossover trial indicated concerns in most domains (Fig. 3) [34].

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Impact on procedural accuracy and efficiency

Endodontic tasks have demonstrated significant improvements in accuracy and efficiency when facilitated through virtual reality (VR) training. Specifically, enhancements have been observed in the preparation of root canals and access cavities. Several studies showed that students trained with the VR simulations made fewer procedural errors and had a shorter completion time while being more spatially aware than those trained in the traditional educational setting [37]. Simulated environments also enabled students to refine motor skills and build their expertise through the repetition of complex endodontic techniques [34].

Influence on student confidence and skill acquisition

Those who interacted with VR-based e-learning platforms showed an increased level of confidence in their ability to perform endodontic procedures. VR training offered a low-pressure, controlled setting with the ability to practice without the risk of harming real patients [31]. The immersive experience of VR enabled them to see and simulate the steps as they happened and allowed for virtual haptic feedback, which facilitated knowledge retention and skill acquisition. Students trained in VR, compared to traditional training, were significantly better at performing exact endodontic manoeuvres [19].

Error reduction

Key to preventing procedural oversights was the ubiquitous use of real-time feedback on the VR simulations. The studies suggested that students who received training with VR made significantly fewer errors in terms of instrument angulation, cavity preparation depth, and inappropriate entry into the root canal system [36].

Satisfaction and perception

The consensus of students was that VR-based learning provided an immersive and interactive experience that they believed to be beneficial. Many found that VR increased engagement and motivation to learn, paralleling real-world clinical practice [6, 38]. Furthermore, participants appreciated the flexibility and adaptability of VR training, as it allowed learners to rehearse procedures when and where it was convenient for them. This confirms the educational value of endodontic simulation in terms of student satisfaction when comparing VR and traditional methods. Table 7 provides a summary of student feedback and learning outcomes, indicating satisfaction, usability, and effectiveness of VR-based training.

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Although the majority of included studies reported favourable outcomes associated with VR-based endodontic training, a few studies highlighted limitations or mixed findings. Slaczka et al. (2024) reported no statistically significant difference in performance improvement between students trained with Simodont and those using traditional artificial teeth, though student satisfaction with VR remained high. Diegritz et al. (2024) found no significant improvement in pre- and post-intervention scores, suggesting that while the VR application was well-received, its impact on learning outcomes was limited. Ba-Hattab et al. (2023) concluded that VR Dental Simulators (VRDS) served best as complementary tools rather than replacements for conventional methods.

Discussion

The results from this systematic review suggest that VR simulation improves accuracy, efficiency, and confidence in students entering the field of endodontics. In addition, the learners receive immediate feedback from the simulation, allowing them to identify and reduce the errors that would otherwise occur if the procedure were performed in the actual operating room. Furthermore, students reported being satisfied with VR-based training, noting it as an effective form of training considering that engagement and skill are also enhanced through it.

Other studies have also emphasized the benefits of VR use in dental education [1]. It has been suggested that the advantages of VR over traditional methods of teaching include unlimited practice hours with objective feedback and improved skill acquisition [1] which can help support simulation-based learning in dental education. Our systematic review’s findings are in agreement with these observations reinforcing the role of VR in the acquisition of psychomotor skills and procedural accuracy.

From this viewpoint, Li et al. wrote a landscape review aimed at visualizing the current usage and potential of simulators in dental education [3]. They pointed out that virtual reality-based simulators can augment or replace conventional approaches, especially in preclinical education. However, they commented on limitations associated with cost, infrastructure, and the need to train faculty, all issues that were also recognized in our review. In conclusion, we have shown that although VR has great potential in dental education, its implementation in the medical curriculum should be approached with thought and investment.

Also, Moussa et al. conducted a systematic review of studies focused on the efficacy of VR and interactive simulators in dental education [5]. Based on 73 studies included in their review, the authors found that broadly VR-based training positively impacted most educational outcomes, with significant effect sizes in 52 studies evaluating various outcomes. Our review reflects these findings, particularly in the positive impact of VR on procedural accuracy, confidence, and knowledge retention. Our review has also shown that students have been generally favourable in their attitudes towards VR training, which further substantiates these findings.

Higgins et al. conducted a scoping review of public engagement efforts in “One Health” research; their findings suggest opportunities for incorporating public engagement and reflections within a More-Than-Human Research Assemblage [44]. Those in dentistry who have explored simulation-based education observed a gap in high-quality studies assessing the impact on long-term clinical outcomes. They noted the call for further longitudinal studies to assess whether VR-trained students can maintain their skills when entering into clinical practice. This is consistent with our review’s finding that although VR is strongly associated with enhanced student performance in a simulated environment, the long-term advantages of VR application in a clinical context still require further exploration.

Recent evidence underscores the importance of aligning simulation-based dental education with student preferences—not only in digital interfaces but also in the instruments simulation. In a multicentre simulated study by Puleio et al., dental students evaluated four Ni-Ti rotary systems (MTwo, SlimShaper Pro, ProTaper Gold, and HyFlex EDM) and expressed a clear preference for instruments with smaller taper and martensitic alloy composition, citing improved flexibility, reduced procedural complexity, and enhanced tactile feedback. Incorporating such user-centered insights into VR-based endodontic training could significantly enhance its effectiveness, particularly for novice learners. While this review primarily focuses on Virtual Reality (VR), it is equally important to acknowledge the emerging role of Augmented Reality (AR) in dental education and clinical procedures. AR facilitates real-time digital overlays onto the physical environment, enhancing spatial orientation and procedural precision. The study also demonstrated AR’s capacity to improve accuracy in various clinical dental interventions, including implant placement, caries detection, and surgical navigation. Integrating both VR and AR technologies into preclinical training could bridge the gap between theoretical knowledge and hands-on skill development, ultimately fostering a more immersive and effective learning environment [45].

Although the review acknowledges cost and accessibility as primary barriers to implementing VR technologies in dental education, further elaboration is warranted. VR systems such as Simodont®, which are widely used in dental schools, can cost between USD 80,000 to 100,000 per unit, not including ongoing maintenance and software licensing fees. In contrast, traditional phantom-head simulators and plastic teeth are significantly less expensive but lack real-time feedback and immersive environments. A recent study by Widbiller et al. (2018) suggested that while the initial investment in VR is high, the reduction in material costs, reusability, and repeatability of training may offer long-term economic advantages. Moreover, integrating shared VR labs or simulation centers across departments could amortize costs and improve institutional feasibility. To fully understand cost viability, future studies should perform formal cost-effectiveness analyses comparing VR, AR, and traditional teaching modalities in terms of educational outcomes per unit of expenditure [46].

There are several strengths of this systematic review which augment the robustness and completeness of the findings. A major strength is the database search was comprehensive, and an extensive literature review was conducted in several databases. This method reduced the risk of excluding relevant studies and gave a balanced overview of this recent technology in endodontic education. Another strength of the manipulation is that it provided a comprehensive risk of bias assessment. The methodological quality of the included studies was assessed using a variety of validated tools. Additionally, incorporating various types of study designs, including randomized controlled trials (RCTs), quasi-experimental studies, systematic reviews, and observational studies, enabled a more comprehensive and inclusive examination of the evidence. As a result of the inclusion of study designs, this review arms with a broader comprehension of the influence of VR on endodontic training.

However, it should be noted that there are also several limitations of the review. A significant limitation is the diversity of VR systems used in the included studies. The heterogeneity of VR platforms, software, and hardware made direct comparisons between studies difficult and may have contributed to the variability in findings. Another critical limitation is the relatively small sample sizes in many studies, which may restrict the generalizability of the results and fail to capture the full spectrum of learning outcomes among dental students. Additionally, most studies lacked long-term follow-up. While immediate improvements in learning outcomes following VR-based training are well-documented, evidence on the durability of these effects and their translation into clinical practice remains limited. One of the key gaps identified across the included studies is the absence of long-term follow-up to determine whether the skills acquired through VR training are retained over time and result in improved clinical performance. To address this, future research should adopt standardized follow-up durations—such as 6 months, 1 year, and 2 years post-training—and incorporate objective outcome measures, including OSCE scores, procedural error rates in real patients, or clinical case success rates. The use of prospective cohort designs or randomized controlled trials with longitudinal arms is recommended to provide more robust evidence of the sustained impact of VR-based education. Given the variability of platforms, a supplementary table (Supplementary Table 1) has been provided to classify VR systems based on their realism, interactivity, and feedback mechanisms, to support interpretability and replication.

While the present review acknowledges the diversity in VR platforms, training durations, and instructional models, it is evident that the absence of standardization across studies limits the comparability and generalizability of outcomes. To optimize the educational impact of VR-based endodontic training, future efforts should focus on developing standardized implementation protocols that ensure consistent learning outcomes across institutions. Establishing such protocols would facilitate uniform assessment methods, curricular alignment, and integration into national competency frameworks. Incorporating VR into existing dental curricula also presents pedagogical and logistical challenges. These include aligning simulation exercises with course objectives, defining appropriate assessment metrics, and ensuring adequate faculty training. Educators must be equipped with the necessary skills to effectively deliver VR-based content and provide personalized learning experiences. Additionally, practical considerations such as scheduling, hardware maintenance, and student workload calibration must be addressed to support seamless integration.

Cost-effectiveness analyses are essential to evaluate the financial feasibility of widespread VR adoption in dental education. Understanding the economic implications will help institutions make informed decisions regarding investment in such technologies. Furthermore, although many studies report short-term improvements in procedural performance and confidence, the long-term efficacy of VR training remains unclear. Most existing studies are limited by small sample sizes and lack extended follow-up. Thus, we recommend well-powered, multicentre, longitudinal research to assess the retention, clinical transferability, and patient-related outcomes of skills acquired through VR simulation.

Conclusion

This systematic review highlights the significant impact of VR simulation on improving procedural accuracy, student confidence, and error reduction in endodontic education. Despite some limitations, VR presents a promising approach to supplement traditional training methods. Future studies should focus on long-term clinical effectiveness and cost feasibility to facilitate the broader adoption of VR-based learning in dental curricula.

Data availability

Data will be made available by the corresponding author upon reasonable request.

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