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

Abstract

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.

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.

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.

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.

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).

Table 1. Search criteria based on PICO format

Search Found	PICO	Search Strategy Input Query	No. of Items
PubMed Database Search
(#1)	Population 1	“dental student*“[Text Word] OR “undergraduate dental“[Text Word] OR “dental undergraduate*“[Text Word] OR “dentistry“[Text Word] OR “stomatology“[Text Word] OR “students, dental“[MeSH Terms]	114,539
(#2)	Population 2	“endodontics“[MeSH Terms] OR “Access cavity“[Text Word] OR “endodontic education“[Text Word] OR “root canal anatomy“[Text Word] OR “endodontics/education“[MeSH Terms] OR “root canal preparation/methods“[MeSH Terms] OR “RCT“[Text Word] OR “root canal preparation“[Text Word]	72,737
(#3)	Intervention	“Computer simulation“[MeSH Terms] OR “simulation training“[MeSH Terms] OR “haptic technology“[MeSH Terms] OR “Virtual reality“[MeSH Terms] OR “virtual simulation“[Text Word] OR “Virtual reality“[Text Word] OR “simodont“[Text Word] OR “VR“[Text Word] OR “haptic“[Text Word] OR “simulation*“[Text Word] OR “Augmented reality“[Text Word] OR “AR“[Text Word]	804,381
(#4)	Outcome	“accuracy“[Text Word] OR “perception*“[Text Word] OR “procedural error“[Text Word] OR “completion time“[Text Word] OR “tooth mass“[Text Word] OR “questionnaire*“[Text Word] OR “theoretical“[Text Word] OR “feedback*“[Text Word] OR “error reduction“[Text Word] OR “confidence“[Text Word] OR “knowledge retention“[Text Word] OR “knowledge“[Text Word] OR “satisfaction“[Text Word] OR “error*“[Text Word]	4,717,596
(#5)		#1 AND #2	2941
(#6)		#2 AND #3	1025
(#7)		#1 AND #2 AND #3	49
(#8)		#1 AND #2 AND #3 AND #4	34
Google Scholar Database Search
(#1)	“virtual simulation” OR “VR” OR “virtual reality” AND dental students OR “undergraduate dental” AND “root canal” OR “endodontic”	525	(#1)
Cochrane Library Database Search
(#1)	(virtual reality OR simulation training) AND (endodontic education OR root canal*)	22	(#1)

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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Fig. 1

PRISMA flow diagram

Table 2. List of studies that were excluded after full-text search and reasons for exclusion

Sl. No	Study	Reason for exclusion
1.	Fouillen et al., 2023 [9]	No virtual simulation component
2.	Bosshard et al., 2023[10]	Apicectomy; study population different
3.	Delfosse et al., 2023 [11]	No virtual simulation component- 3D print
4.	Fouad et al., 1997 [12]	No virtual simulation component
5.	Chevalier et al., 2022[13]	No virtual simulation component, 3D prints
6.	Janesarvatan et al., 2022[14]	No virtual simulation component, Different study design
7.	Pouhaer et al., 2022[15]	No virtual simulation component, 3D prints
8.	Hohne et al., 2019[16]	No virtual simulation component, 3D prints
9.	Reymus et al., 2019[17]	No virtual simulation component, 3D prints
10.	Widbiller et al., 2018 [18]	No virtual simulation component
11.	Kaluschke et al., 2017 [19]	Different study population
12.	Robberecht 2017 [20]	No virtual simulation component
13.	Wolgin et al., 2017 [21]	No virtual simulation component
14.	Pohlenz 2010[22]	Different procedure (Endodontic surgery)
15.	Marras et al., 2008[23]	Lack of study population
16.	Littlefield et al., 2003[24]	No virtual simulation component
17.	Lan Ma et al., 2024 [25]	Different procedure (Apexification)
18.	San Diego et al., 2022 [26]	Different procedure (Cavity preparation)
19.	Wu et al., 2021 [27]	Different intervention
20.	Tsukauda et al.,2023[28]	Different study population
21.	Philip et al., 2023 [29]	Different procedure (Pulpotomy)
22.	Dolegowsky et al., 2023[30]	Different study population

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.

Table 3. Study characteristics of the selected articles

Sl. No.	Author(s)	Year	Journal	Title	Objective	Study Design	Location	Participants
1	Riyadh Alroomy et al. [35]	2024	European Endodontic Journal	Students’ Perception of Remote Extended Reality Simulation Systems Using Patient-specific 3D-printed Models	To investigate student perceptions of XR simulation for transferring endodontic educational information.	Cross-sectional study	Japan and Saudi Arabia	11 fifth-year dental students (6 males, 5 females). 3 had prior VR experience. 8 did not.
2	Fahd Alsalleeh et al. [40]	2024	Applied Sciences	Augmented Reality Improved Knowledge and Efficiency of Root Canal Anatomy Learning: A Comparative Study	To evaluate AR as a pedagogical tool for teaching root canal anatomy compared to CBCT methods.	Non-randomized study	King Saud University, Riyadh	43 third-year dental students (18 males, 25 females)
3	Mengting Duan et al. [41]	2024	BMC Medical Education	Effect of 3D Printed Teeth and Virtual Simulation System on Pre-Clinical Access Cavity Preparation Training	To evaluate the effectiveness of 3D printed teeth and virtual simulation systems in training dental undergraduates.	Non-randomized study	Wuhan University, China	98 senior dental students (42 males, 56 females)
4	Ba-Hattab et al. [2]	2023	Applied Sciences	Impact of Virtual Reality Simulation in Endodontics on the Learning Experiences of Undergraduate Dental Students	To evaluate the impact of Virtual Reality Dental Simulators (VRDS) on preclinical training in endodontics.	Non-randomized study	Qatar University (Qatar), Ankara University (Turkey)	60 third-year dental students (14 from Qatar, 46 from Turkey)
5	Min-Hsun Hsu et al. [36]	2022	Journal of Dental Sciences	Virtual 3D Tooth Creation for Personalized Haptic Simulation Training in Access Cavity Preparation	To explore the use of a 3D virtual tooth model created from CBCT for haptic simulation training in access cavity preparation.	Cross-sectional study	Chung Shan Medical University, Taichung, Taiwan	5 dental interns and postgraduate dentists
6	Christian Diegritz et al. [38]	2024	International Endodontic Journal	Tooth Anatomy Inspector: A Comprehensive Assessment of an Extended Reality (XR) Application for Teaching Root Canal Anatomy	To evaluate the efficacy of an XR-based application for teaching root canal anatomy to undergraduate students.	Pre-Post study	LMU Munich, Germany	61 third-year dental students; 57 completed training (17 males, 40 females)
7	Damian M. Slaczka et al. [32]	2024	International Endodontic Journal	Endodontic Access Cavity Training Using Artificial Teeth and Simodont® Dental Trainer	To compare the performance and acceptance of students trained using Simodont® vs. artificial teeth.	Randomized controlled study	University of North Carolina, USA	40 dental students (29 s-year, 11 first-year; 21 males, 19 females)
8	Siriwan Suebnukarn et al. [6]	2010	Journal of Dental Education	Augmented Kinematic Feedback from Haptic Virtual Reality for Dental Skill Acquisition	To evaluate the impact of augmented kinematic feedback on the acquisition and retention of dental skills.	Randomized controlled trial	Thammasat University, Thailand	32 dental students (16 males, 16 females; 8 participants per group)
9	Maximilian Kaluschke et al. [19]	2023	PLOS ONE	The Effect of 3D Stereopsis and Hand-Tool Alignment on Learning Effectiveness and Skill Transfer of a VR-Based Simulator for Dental Training	To evaluate the effects of 3D stereopsis and hand-tool alignment on VR-based dental simulator effectiveness and skill transfer.	Randomized controlled trial	Mahidol University, Thailand	40 fifth-year dental students (12 males, 28 females)
10	Jiaxuan Lu et al. [31]	2022	BMC Medical Education	Effect analysis of a virtual simulation experimental platform in teaching pulpotomy	To assess the efficacy of a virtual simulation experimental platform in pulpotomy teaching.	Randomized controlled trial	Sun Yat-sen University	199 fourth-year stomatology students
11	Marcel Reymus et al. [37]	2020	International Endodontic Journal	Virtual reality: an effective tool for teaching root canal anatomy to undergraduate dental students	To evaluate the effectiveness of virtual reality (VR) as a teaching tool for root canal anatomy.	Cross-sectional study	University Hospital of Munich	42 third-year dental students
12	Siriwan Suebnukarn et al. [43]	2014	Journal of Dental Education	Construct Validity and Expert Benchmarking of the Haptic Virtual Reality Dental Simulator	To demonstrate construct validity of the haptic VR dental simulator and establish expert benchmarking criteria for skill assessment.	Non-randomized study	Thammasat University, Thailand	34 participants (14 novices, 14 intermediates, 6 experts)
13	Siriwan Suebnukarn et al. [6]	2010	Journal of Endodontics	Haptic Virtual Reality for Skill Acquisition in Endodontics	To assess skill acquisition in endodontics using haptic VR and identify variables for proficiency quantification.	Pre-Post study	Thammasat University, Thailand	20 novice dental students (11 males, 9 females)
14	Siriwan Suebnukarn et al.[33]	2011	International Endodontic Journal	Access cavity preparation training using haptic virtual reality and microcomputed tomography tooth models	To evaluate the effectiveness of haptic VR training using micro-CT tooth models in reducing procedural errors in endodontic access cavity preparation.	Randomized controlled trial	Thammasat University, Thailand	32 fourth-year dental students (16 experimental, 16 control)
15	Wei Y, Peng Z[34]	2024	PLOS ONE	Application of Simodont virtual simulation system for preclinical teaching of access and coronal cavity preparation	To evaluate the effectiveness of the Simodont virtual simulation system for preclinical dental training.	Randomized controlled trial	Sun Yat-sen University	20 fourth-year dental students

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].

Table 4. Cross-sectional quality assessment using the Newcastle-Ottawa scale

Criteria		Alroomy et al., 2024 [35]	Hsu et al., 2022 [36]	Reymus et al., 2020 [37]
Selection	Representative of the cases	-	-	-
	Sample size	-	-	-
	Non-respondents	-	*	*
	Ascertainment of the screening/surveillance tool	*	0	*
Comparability		-	-	-
Outcome	Assessment of the outcome	*	*	**
	Statistical test	*	0	*
Total (maximum 10)		3*	2*	5*
Overall Quality Assessment		Poor	Poor	Moderate

Table 5. Risk of Bias for Before–After (Pre–Post) studies with no control group

Sno	Criteria	Diegritz et al., 2024 [38]	Suebnukarn et al., 2010 [6]
1	Study objective clear	Y	Y
2	Eligibility criteria clearly described	N	Y
3	Participants representative	N	N
4	All eligible enrolled?	N	N
5	Sufficient sample size	N	N
6	Intervention is clearly described	Y	Y
7	Outcomes pre-specified and clearly described	N	Y
8	Blinding of assessors	N	Y
9	Lost to follow up 20% or less	Y	NR
10	Statistical analysis	Y	Y
11	Multiple outcome measures	N	N
12	Individual level data to determine group effect	NA	NA
	Total score	7	4
	Overall risk	M	M

Y = yes; N = no; NR = not reported; NA = Not applicable. Scoring for overall risk of bias assessment is as follows: 0–3 N, Low risk of bias (L); 4–8 N, Moderate risk of bias (M); 9–11 N, High risk of bias (H)

Table 6. MINORS tool for non-randomized studies without a comparator group

Criteria	Alsalleeh et al., 2024 (“Augmented Reality Improved Knowledge and Efficiency of Root Canal Anatomy Learning: A Comparative Study,” n.d.) [40]	Duan et al., 2024 [41]	Ba-Hattab et al., 2023 [2]	Suebnukarn et al., 2014 [43]
1. A clearly stated aim	2	2	2	2
2. Inclusion of consecutive patients	0	0	1	2
3. Prospective collection of data	0	1	0	0
4. Endpoints appropriate to the aim of the study	2	2	1	1
5. Unbiased assessment of the study endpoint	1	0	0	1
6. Follow-up period appropriate to the aim of the study	1	1	1	1
7. Loss to follow up less than 5%	0	0	0	2
8. Prospective calculation of the study size	1	0	0	0
Total score	7/16	6/16	5/16	9/16
Overall quality	poor	Poor	Poor	Moderate

0 = Not reported; 1 = Reported but inadequate; 2 = Reported and adequate;

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Fig. 2

ROB-2 assessment of randomized controlled trials

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Fig. 3

ROB-2 assessment of crossover trials

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.

Table 7. Summary of interventions, outcomes, and findings from the selected studies

Author(s)	Intervention	Outcomes Measured	Statistical Analysis	Findings	Strengths	Limitations	Conclusion
Riyadh Alroomy et al. [35]	XR simulation using head-mounted devices (Oculus2, Meta Quest 2). Students interacted with 3D models created from CBCT data. Sessions included virtual tooth anatomy and root canal access using 3D-printed guides.	1. Tooth Anatomy	Independent t-tests to evaluate sex-based and VR experience differences. Means ± SD calculated. p < 0.05 was significant.	Highest satisfaction: Tooth anatomy (4.6 ± 0.4) and emotional impression (4.5 ± 0.5)	High immersion with XR devices	Small sample size (n = 11) limits generalizability	XR can enhance dental education, particularly for remote learning. Satisfaction was high for anatomy and emotional impressions, but data transmission needs improvement.
		2. Root Canal Access		Lowest satisfaction: Data transmission (3.5 ± 0.9)	Effective integration of VR into online education	Wi-Fi instead of 5G affected data transmission
		3. Usability		Female participants had significantly higher satisfaction in data transmission (p = 0.007).	Simulated real-world dental procedures	No long-term effects of XR studied
		4. Emotional Impression
		5. Data Transmission
Fahd Alsalleeh et al. [40]	CBCT analysis on 2D monitors followed by AR exploration using Meta Quest 2 headset. Questions on anatomy asked after each method, with a 4-week interval between sessions.	Root canal identification, classification (Weine’s system), and time efficiency.	Paired t-tests (CBCT vs. AR), mixed-model ANOVA for gender differences. Significance level p < 0.05.	AR scores significantly higher than CBCT (mean difference 3.95, p < 0.05). Females performed better with AR (mean difference 6.04, p < 0.001). Time for AR (M = 4.09 min) was significantly shorter than CBCT (M = 15.21 min, p < 0.001). 93% preferred AR.	AR improved comprehension, efficiency, and student satisfaction (93%). Effective for complex anatomy simulations.	Limited sample size, sequential design (potential learning order effects), no long-term clinical impact assessed, limited AR bandwidth for simultaneous users.	AR enhances learning efficiency and comprehension in dental education. Needs further exploration for long-term impact and curricular integration.
Mengting Duan et al. [41]	Access cavity preparation training using three methods: commercial plastic teeth, 3D printed teeth, and virtual simulation systems, with scores and feedback collected through questionnaires.	Scores on access cavity preparation quality, valid/invalid removal ratios, and student feedback.	Non-parametric Wilcoxon Signed Ranks Test. Statistical significance set at p < 0.05.	No significant difference between plastic and 3D-printed teeth overall.	Comprehensive comparison of three training methods.	Small sample size limited to one university.	Virtual simulation followed by plastic and 3D-printed teeth training offers an effective sequence. Virtual simulation cannot fully replace traditional methods. Further material and system refinements needed.
				Virtual simulation valid area removal: 96.86%±5.08%.	High student agreement on integrating virtual and 3D training.	Long-term impact of training methods not studied.
Ba-Hattab et al. [2]	VRDS training (SIMtoCare in Qatar; Simodont in Turkey) vs. traditional endodontic training on natural and acrylic teeth. Participants trained on endodontic access cavity preparation and completed a structured questionnaire post-training.	Learning experiences with VRDS	One-way ANOVA to assess variation in responses between institutions. Data analyzed using RStudio.	85% supported VRDS to complement conventional methods.	Opportunities for repeated practice.	Small sample size limited to two institutions.	VRDS can supplement traditional training in endodontics but cannot fully replace it. Recommendations include integrating VRDS earlier in the curriculum and enhancing its functionality for better clinical preparation.
		Motor skill improvement		76% found VRDS helpful for motor skills.	Low risk, eco-friendly training environment.	Single exercise assessed.
		Confidence in endodontics		Perceived VRDS similarity to natural teeth: 73%, acrylic teeth: 53%.	Improved motor skills and reduced stress.	Limited longitudinal follow-up of students’ transition to clinical settings.
		Ease of VRDS training		VRDS cannot fully replace traditional methods.	Automated feedback for student learning.	Software and hardware improvements recommended.
Min-Hsun Hsu et al. [36]	Developed a patient-specific virtual 3D tooth (#26) using CBCT data and 3DSlicer software. The STL file was imported into the Simodont VR simulator for unlimited practice of access cavity preparation.	Perceptions of VR simulation	Not applicable (qualitative analysis based on participant feedback).	VR simulation allowed realistic and repeated practice.	Reduced waste and cost for repeated practice.	Small sample size with limited participants.	VR simulation using patient-specific 3D models is a promising tool for dental education, reducing errors and enhancing realism. Further improvements are needed to enhance functionality and segmentation accuracy.
		Procedural accuracy		Customized 3D tooth facilitated reduced procedural errors.	Environmentally friendly.	The monochromatic STL model lacked enamel/dentin differentiation.
		Error reduction		Participants found the module beneficial for practice.	Customized patient-specific models improve clinical relevance.	Limited to access cavity preparation.
					Easy STL creation with open-source software (3DSlicer).	Metal artifacts on CBCT images reduced segmentation accuracy.
Christian Diegritz et al.[38]	Developed a mobile and VR-compatible application using µCT-scanned STL models of human teeth. Students used the app on tablets and VR glasses, explored 3D tooth models, and adjusted transparency levels for learning root canal anatomy. Post-training questionnaires evaluated learning outcomes and user experience.	Perceived ease of use, motivation, understanding of anatomy, comparison with traditional methods, and preference for XR integration.	Kolmogorov-Smirnov test for normality and Mann–Whitney U test for pre/post differences (p = 0.05).	Students found the application user-friendly (98%) and motivating (100%).	Combines AR and VR for enhanced learning.	No objective evaluation of learning outcomes.	XR-based tools effectively supplement traditional teaching methods in dental education. They enhance motivation and provide flexibility but cannot replace lectures or hands-on guidance.
				No significant difference in pre/post scores, indicating consistency of expectations and outcomes.	Cost-effective and accessible with mobile devices.	Results limited to self-reported data.
				XR was seen as a valuable supplement but not a replacement for traditional teaching.	Enables independent learning and exploration of anatomical details.	Did not compare effectiveness with other tools like the 3D Tooth Atlas.
						Not tested for long-term impact on clinical skills.
Damian M. Slaczka et al. [32]	Simodont group practiced virtual endodontic access on mandibular 1st molar for 60 min; artificial teeth group practiced using physical teeth mounted on phantom heads. Training followed by evaluations using a standardized rubric and Likert-scale questionnaire for feedback.	Improvement in scores (baseline to re-evaluation), student perceptions of usability, effectiveness, and haptic feedback.	Fisher’s exact test for performance improvement; Cohen’s kappa for intra- and inter-examiner agreement.	No significant difference in improvement between groups (Simodont: 23% improvers, Artificial Teeth: 39%).	Offers repeatability without added cost or waste.	Limited sample size.	Simodont® is a viable adjunct to traditional methods for endodontic training, improving anatomy visualization and usability. Further studies needed to evaluate its clinical impact and cost-effectiveness.
				Simodont improved visualization of pulp chamber anatomy.	Encourages exploration of 3D anatomy.	Results based on short training sessions.
				95% of Simodont users enjoyed the training.	Effective as a supplement to traditional methods.	High costs of Simodont units and space requirements.
				Mixed reviews on haptic feedback realism.	Environmentally friendly.	Limited transferability to clinical settings not assessed.
Siriwan Suebnukarn et al. [43]	Four experimental groups: (1) Force Feedback (F), (2) Mirror Feedback (M), (3) Force-Mirror Feedback (FM), (4) Knowledge of Results Only (KR-only). All groups practiced endodontic access on VR haptic systems for two days, followed by a retention test on day three.	Improvement in overall access preparation score and time to task completion across acquisition and retention sessions.	One-way ANOVA with repeated measures; Tukey’s HSD post hoc analysis for pairwise comparison; dependent t-test for task completion time.	Augmented kinematic feedback groups (F, M, FM) performed significantly better than KR-only during early acquisition and retention sessions.	Detailed real-time feedback on force and mirror use.	Small sample size and limited to VR settings.	Augmented kinematic feedback enhances early-phase skill acquisition and retention. FM feedback was the most effective. Future studies should assess transferability to clinical practice.
				FM group consistently outperformed all others in retention.	Integration of kinematics for procedural analysis.	No evaluation of transferability to real clinical scenarios.
				Task completion time reduced significantly across sessions.	Effective for novice learners during early skill acquisition.	Lack of direct comparison with non-VR training methods.
Maximilian Kaluschke et al. [19]	Four groups: (1) stereoscopic & aligned, (2) monoscopic & aligned, (3) stereoscopic & misaligned, (4) monoscopic & misaligned. Training involved root canal access on virtual tooth followed by assessments on plastic teeth. Outcomes assessed using automated scoring and expert evaluation.	Error reduction during real and virtual tasks	Paired t-tests, ANOVA, correlation analysis (p < 0.05 for significance).	Hand-tool alignment significantly improved real-world learning gains (p = 0.0598).	Comprehensive analysis of VR factors on dental training.	Limited sample size.	Monoscopic rendering with hand-tool alignment is most effective for VR-based dental training. Future simulators should optimize these factors for better skill transfer.
		Impact of stereoscopic rendering and hand-tool alignment on performance		Monoscopic rendering led to higher learning gains compared to stereoscopic rendering (p = 0.082).	Innovative use of automated scoring metrics.	No long-term follow-up for skill retention.
		Correlation of real-world and VR simulator learning		Group with monoscopic & aligned conditions showed the best skill transfer (R = 0.49).	Detailed insights into stereoscopic rendering limitations.	Limited to root canal access training.
						Eye-tooth distance differences affected stereoscopic rendering outcomes.
Jiaxuan Lu et al. [31]	Experimental group used a virtual simulation platform for pulpotomy (practice and test modes) alongside theoretical training. Control group followed a conventional teaching approach with no simulation practice.	Theoretical and practical scores	SPSS 20.0 for one-way ANOVA and t-tests for multiple comparisons. Statistical significance: p < 0.05.	Significant improvement in grades for the experimental group in practical and theoretical examinations (p < 0.05).	Provides realistic, repeatable practice without time and space constraints.	Simulation restricted to specific tooth types and clinical scenarios.	Virtual simulation platforms improve pulpotomy teaching outcomes and student engagement. Regular updates and integration into broader curricula recommended.
		Student satisfaction and feedback after using the platform		> 90% of students in the experimental group appreciated the teaching platform, citing increased enthusiasm and learning retention.	Interactive features enhance autonomous learning.	Cannot replicate the complexity of real clinical cases.
					Complements theoretical and traditional training.	No long-term impact assessment.
Marcel Reymus et al. [37]	Students inspected root canal anatomy using three methods: radiographs, CBCT scans, and VR models. VR utilized CBCT-derived 3D models viewed in a head-mounted display. Outcomes included student comprehension and method preference.	Detection of root canals	Mc Nemar’s and binomial tests; Cronbach alpha for questionnaire reliability. Significance: p < 0.05.	VR outperformed radiographs (p < 0.001) and was comparable to CBCT in comprehension and anatomy detection.	Interactive and immersive learning environment.	Small sample size and single institution.	VR is a promising tool for teaching root canal anatomy, with comparable results to CBCT and greater engagement. Further research on clinical outcomes is needed.
		Perceived comprehension of anatomy		Majority preferred VR for future learning (30/42).	Affordable VR tools used.	Non-randomized sequence of methods.
		Students’ method preference		VR enabled interaction and better visualization of anatomical features.	Increased student engagement and satisfaction compared to traditional methods.	Short-term evaluation only; no long-term retention or clinical application assessment.
Siriwan Suebnukarn et al. [43]	Participants performed endodontic access opening in three modes (easy, medium, hard) using a haptic VR simulator. Error scores and instrument path length were measured over 10 trials per mode, and outcomes were compared between novices, intermediates, and experts.	Error scores	One-way ANOVA for group differences; Tukey HSD for post hoc analysis. Significance: p < 0.05.	Significant differences in error scores and path length between groups in easy and medium modes.	Validated the haptic VR simulator as a discriminative tool for skill levels.	Small sample size, especially for expert group.	Haptic VR dental simulators are effective tools for differentiating skill levels and establishing benchmarks. They enhance skill acquisition and consistency with repeated practice.
		Instrument path length		Experts performed consistently better initially but differences reduced with training.	Provided quantifiable benchmarks for novices to achieve expert-level performance.	Limited to preclinical tasks; no real clinical validation.
		Learning curve progression		Hard mode did not differentiate groups effectively by error scores but did with path length.	Demonstrated learning curve improvement with practice.	Hard mode lacked discriminatory power in error scores.
						Short-term outcomes only.
Siriwan Suebnukarn et al. [39]	Participants performed an endodontic access opening task using a haptic VR system. Measurements included time to task completion, force utilization, and bimanual coordination before and after five training sessions.	Time to task completion (T)	Paired t-tests for pre- and post-training comparisons (p < 0.05).	Significant improvement in time to task completion, force utilization, and bimanual coordination post-training.	Provides real-time kinematic data.	Small sample size limited to novices.	Haptic VR is effective for improving endodontic skills in novices, offering detailed insights into skill acquisition. Future research should evaluate clinical skill transfer.
		Force utilization (F)		Outcome scores improved with training.	Identifies specific skill deficiencies.	No expert comparison.
		Bimanual coordination (M)		Participants developed unique patterns for force utilization and coordination.	Allows repetitive and controlled training.	Focused on preclinical training only.
		Outcome scores (O)			Objective proficiency metrics established.	Short duration of study; no long-term retention data.
Siriwan Suebnukarn et al. [33]	Experimental group trained on micro-CT tooth models using a haptic VR simulator; control group trained on extracted teeth mounted on phantom heads. Both groups underwent 3 days of training (2 h per day).	Procedural errors (score of 0–15)	Wilcoxon test for pre/post differences within groups; Mann–Whitney test for differences between groups. Independent t-test for mass removed and completion time.	Both groups showed significant reductions in procedural error scores post-training (p < 0.05).	Demonstrated effectiveness of VR for minimal tissue removal training.	Small sample size.	Haptic VR training with micro-CT tooth models is as effective as traditional methods for minimizing procedural errors. VR provides added benefits for conserving tooth structure.
		Tooth mass removed (grams)		VR group reduced tooth mass removal significantly compared to the control group (p < 0.05).	Provided augmented feedback with real-time performance analysis.	Limited training duration (3 days).
		Task completion time (minutes)		No significant difference in task completion time between groups.	Comparable performance to conventional methods.	Did not assess long-term skill retention or transfer to clinical practice.
						Limited to specific access cavity preparation tasks.
Wei Y, Peng Z [34]	Participants divided into two groups (Simodont priority and phantom-simulator priority). Training included preparation of access and coronal cavities on virtual simulation systems and traditional phantom-simulators. Outcomes were assessed after training sessions and analyzed.	Scores on access and coronal cavity preparation	Two-sample t-test and one-way ANOVA (LSD/Dunnett T3 method). Significance set at p < 0.05.	Combining Simodont and phantom-simulators yielded significantly better results than single methods.	Combined training approach showed additive benefits.	Small sample size (n = 20) limited generalizability.	Simodont, when combined with traditional simulators, enhances training outcomes for access and coronal cavity preparation. Further upgrades to Simodont could increase its standalone utility.
		Student feedback through questionnaires		Simodont priority group performed better overall in post-training assessments (p < 0.05).	Simodont system provided enhanced feedback and allowed multiple practice attempts.	Short-term study; no evaluation of long-term skill retention.
		Sequence effects on training outcomes		Students highlighted Simodont’s repetitive practice and attention to detail but noted room for improvement.	Effective in initial stages of dental skill training.	Students found the Simodont less realistic compared to phantom-simulators.

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.

Acknowledgements

The authors gratefully acknowledge the financial support provided by Ajman University, UAE, for covering the article’s APC.

Author contributions

The research question, search strategy and aim of the study were designed through discussion between M.Q.J., B.A., S.H.K., and M.S.Z; B.A., S.H.K., S.A., and A.M.A., searched and extracted the data from the included papers; M.Q.J. B.A. and M.S.Z. revised the results and interpreted the data; Discussion and conclusion were produced based upon a dialogue between M.Q.J., A.M.A., and S.A. All authors read and approved the final manuscript.

Funding

The authors gratefully acknowledge the financial support provided by Ajman University, UAE, for covering the article’s APC.

Data availability

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

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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