Impact of Virtual Patient-Based Learning on Temporomandibular Disorder Knowledge among Dental Students: A Pre-Post Study

Abstract

Objectives:

Temporomandibular disorders (TMD) are common in dental practice, yet dental students report limited confidence and competence due to insufficient clinical exposure during predoctoral training. Virtual patient–based learning (VPBL) may enhance experiential learning; however, its impact on clinically relevant educational outcomes remains underexplored. This study evaluated whether a TMD-specific VPBL educational intervention improves dental students’ diagnostic and management performance, self-perceived confidence, and knowledge.

Methods:

This quasi-experimental pre-post study included 83 fourth-year dental students at Adams School of Dentistry, University of North Carolina. Participants completed pre- and post-intervention assessments consisting of five Objective Structured Clinical Examination (OSCE)-style case scenarios evaluating TMD-related diagnostic and management skills. Between assessments, students reviewed 15 TMD virtual patient cases. Performance was scored using a predefined rubric across diagnostic accuracy, diagnostic reasoning, management appropriateness, justification for additional testing, and understanding of systemic/local factors influencing TMD (0–10 scale, 10=“higher performance”). Secondary outcomes included confidence in 12 TMD-related skills (0–10 scale) and retrospective pre/post self-perceived knowledge (1–4 scale, 4=“higher knowledge”). Changes were evaluated using paired t-tests and Wilcoxon signed-rank tests.

Results:

100% of the students completed both assessments. Overall performance improved significantly post-intervention (8.3±1.4 vs. 9.4±0.8, p<0.001, effect size=0.64), with gains observed across all domains (all p’s<0.05). Self-perceived knowledge increased significantly (2.6±0.7 vs. 2.9±0.6, p<0.001, effect size=0.70). Overall confidence in TMD-related skills was moderate (5.3±1.7) and positively correlated with post-intervention knowledge (r=.70, p<0.001).

Conclusions:

A TMD-specific VPBL educational intervention was associated with significant improvements in diagnostic and management performance and self-perceived knowledge, supporting its utility as an educational strategy to enhance TMD predoctoral curricula.

1. Introduction

Temporomandibular disorders (TMD) are a group of heterogeneous conditions characterized by pain and/or dysfunction involving the temporomandibular joints, masticatory muscles, and associated structures.¹ TMD affects approximately 30% of the adult population worldwide² and imposes a substantial public health burden.³ Beyond physical discomfort, TMD is associated with increased levels of psychological distress, impaired daily functioning, sleep disturbances, and reduced health-related quality of life.^4–7 Given that initial evaluation and management of TMD typically occur in dental settings, dental providers play a central role in the identification, diagnosis, and management of these conditions. However, levels of TMD-related knowledge^{8, 9} and confidence^10–13 among dental providers and dental students remain consistently suboptimal.

A major factor contributing to inadequate provider confidence and competence is insufficient training during predoctoral dental education. Across U.S. dental schools, TMD instruction relies predominantly on didactic teaching, with limited opportunities for direct clinical exposure to patients with TMD.^{14, 15} However, clinical exposure to patients with TMD has been shown to be a critical determinant of knowledge retention⁹ and self-perceived confidence^{12, 15, 16} among dental students. Without adequate experiential learning, graduates may be less likely to recognize TMD in routine practice or implement appropriate diagnostic and management strategies,¹⁶ perpetuating the cycle of underdiagnosis and undertreatment. Thus, there is a pressing need to revamp TMD predoctoral education by incorporating innovative approaches that enhance clinical exposure and better prepare graduates to deliver evidence-based care to this population.

To address the limited clinical exposure to TMD cases during dental training, our research group developed a Virtual Patient-Based Learning (VPBL) platform featuring 20 virtual patients of the most common TMD and other orofacial pain diagnoses.¹⁷ The platform was designed to simulate authentic clinical encounters, provide a structured, standardized approach to evaluating patients presenting with orofacial pain signs and symptoms, and promote active learning through case-based decision making. Prior work has demonstrated the platform’s feasibility, acceptability, and educational suitability,¹⁷ as evaluated by both orofacial pain specialists¹⁸ and end users (i.e., dental students)¹⁷ during Phase I Define-Refine studies. Development and evaluation of the VPBL intervention were guided by the Obesity-Related Behavioral Intervention Trials (ORBIT) model, a rigorous, phased framework for design and testing of behavioral interventions targeting chronic conditions.¹⁹ Compared to the traditional ORBIT model, when this framework is used to design and test the implementation of an educational intervention targeting healthcare providers (i.e., students) with the ultimate goal of improving patient care (i.e., ultimate target of the intervention), it is important to assess whether the educational intervention is able to influence the provider behavior, who serve as the intermediate target of the intervention. For dental professionals, critical behavioral outcomes include diagnostic accuracy, clinical reasoning, management decision-making, fundamental knowledge, and self-perceived confidence. These domains are interrelated but distinct. Inadequate diagnostic skills may lead providers to misinterpret signs and symptoms, fail to recognize non-odontogenic pain, or delay referral for interdisciplinary or specialist care.²⁰ Our group has previously shown a positive association between TMD-related knowledge and self-perceived confidence among dental students,^{9, 10} and that providers reporting confidence levels exceeding 50% (on a 0–100 scale) are more likely to screen for TMD during routine care.²¹ However, confidence without sufficient diagnostic and management competencies is unlikely to translate into improved patient outcomes. Therefore, testing educational interventions should target all these behavioral domains to meaningfully impact clinical practice.

The primary aim of this study was to evaluate whether exposure to the VPBL educational intervention improves dental students’ performance in TMD diagnostic and management skills. We hypothesized that overall performance would significantly increase across multiple TMD-related domains from baseline and post-intervention. A secondary aim was to assess change in self-perceived knowledge following the educational intervention. We hypothesized that self-perceived knowledge scores would improve significantly post-intervention compared to baseline. A tertiary aim was to evaluate self-perceived confidence at post-intervention. Sufficient confidence was defined as ≥ 50%, consistent with prior studies showing that providers above this threshold are more likely to apply TMD knowledge in clinical practice.²¹ Because no established benchmark exists for the proportion of participants who should reach this level in an educational intervention, we set an exploratory threshold of ≥ 50% achieving sufficient confidence.

To our knowledge, this is the first study to evaluate changes in behavioral outcomes following the integration of a TMD-specific digital platform into predoctoral dental curricula. In line with the ORBIT framework, findings from this study will inform whether further refinement of the VPBL educational intervention is warranted or whether progression to subsequent phases of testing is appropriate.

2. Methods

The study methodology and results are reported in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) Statement, appropriate for nonrandomized behavioral educational interventions.²²

2.1. Study Design

This was a quasi-experimental, single-group, pre-post study. The study was determined as exempt by the Institutional Review Board (IRB) of the University of North Carolina (25–2118, 27 August 2025 and 25–2262, 2 September 2025). Informed consent was obtained from all participants in accordance with IRB-approved procedures for research considered exempt.

2.2. Participants

Eligible participants were fourth-year dental students enrolled in the DENT717 Course at the Adams School of Dentistry, University of North Carolina, and completed all study-related tasks within the designated study period (see Intervention).

Excluded participants included dental students enrolled in any other academic year, or not participating in study-related tasks within the study timeline.

As part of the predoctoral curriculum, dental students at the University of North Carolina receive longitudinal instruction in TMD content across all four years of training. Foundational concepts are introduced during the first two years through biomedical and clinical sciences coursework (e.g., head and neck anatomy, neuroscience, and oral examination), with reinforcement through clinical correlations and formal assessment. In the third year, students receive structured instruction in orofacial pain and TMD through a dedicated course that includes didactic content and a hands-on laboratory on TMD screening, history taking, clinical examination, diagnosis, and treatment planning. Additional experiential learning occurs within the Continuous Professional Development curriculum, which includes a hands-on session emphasizing muscle examination and differential diagnosis taught by general dentistry faculty and a physical therapist. During the fourth year, students participate in case-based and modular learning activities related to TMD and complete a half-day rotation in the pain clinic, providing supervised clinical exposure to patients with orofacial pain.

Despite this longitudinal exposure, opportunities for repeated, standardized practice in TMD diagnostic reasoning and management decision-making remain variable. The VPBL intervention was designed to complement existing instruction by providing consistent exposure to common TMD presentations and structured opportunities to apply diagnostic and management principles in a controlled educational environment.

2.3. Intervention

2.3.1. Study Procedure.

Figure 1 illustrates the study procedure. Participants first completed a pre-intervention assessment administered via ExamN (eMedley), consisting of five case-based scenarios designed to resemble Objective Structured Clinical Examination (OSCE) presentation. After completing the pre-intervention assessment, participants were granted access to the VPBL platform and instructed to review all virtual patients included in the muscular, articular, and mixed TMD modules within a three-week period (see VPBL Educational Intervention). At the end of the three-week intervention period, participants completed a post-intervention assessment, proctored by supervising staff, which consisted of five novel OSCE-style case scenarios distinct from those used at baseline. These case scenarios were designed to match the baseline cases in scope, complexity, and learning objectives, and were reviewed by content experts (two orofacial pain specialists and two dental educators) to ensure comparable difficulty. Participants were also invited to complete pre-post evaluations through a Qualtrics survey assessing self-perceived knowledge and confidence in TMD-related skills (see Outcome Variables).

Figure 1.

Study procedure.

2.3.2. VPBL Educational Intervention.

As described elsewhere,^{17, 18} the VPBL platform was developed to enhance clinical exposure to TMD cases for predoctoral dental students during their training. The platform comprises four modules (i.e., muscular TMD, articular TMD, mixed TMD, and non-TMD, Figure 2A) classified according to the predominant signs and symptoms featured by the virtual patients. Each module includes five virtual patient cases (Figure 2B), representing the most common diagnoses based on the Diagnostic Criteria for TMD (DC/TMD)²³ and the International Classification of Orofacial Pain (ICOP).²⁴ Completion of each virtual patient was estimated to require approximately 10–15 minutes. All virtual patient cases follow a standardized format (Figure 2C) and incorporate structured clinical information obtained through history taking, medical and psychological history review, imaging interpretation, and comprehensive clinical examination findings. Examination components include extraoral and intraoral assessments, palpation and provocation of the masticatory and cervical muscles, and evaluation of the temporomandibular joints. At the conclusion of each case, learners are prompted to identify the most appropriate diagnosis and management strategy (Figure 2D). Immediate, corrective feedback is provided throughout the case (Figure 2E and 2F), followed by presentation of the correct diagnosis based on established diagnostic criteria and recommendations for evidenced-based management strategies.

Figure 2.

Structure of the VPBL educational intervention.

(A) The VPBL platform is organized into four educational modules (muscular TMD, articular TMD, mixed cases, and non-TMD cases. (B) Each module features five virtual patient case scenarios and presents opportunities for knowledge consolidation with a summative quiz. (C) Every virtual patient presents findings derived from a structured orofacial pain interview. (D) Upon completion of each interview, users are challenged to select the most appropriate diagnosis and corresponding management option, (E, F) from multiple-choice responses with immediate corrective feedback.

For the purposes of the present study, participants were granted access exclusively to the muscular, articular, and mixed TMD modules.

2.4. Outcome Variables

2.4.1. Performance in TMD diagnostic and management skills.

As described above, overall performance in TMD diagnostic and management skill was assessed using five OSCE-style case scenarios at both pre- and post-intervention time points. Each assessment consisted of ten item-based questions scored from 0 to 1 according to a predefined rubric. The questions were organized into five TMD-related domains: diagnostic accuracy, diagnostic reasoning, appropriateness of management skills, justification for additional testing, and understanding of systemic and local factors influencing TMD diagnoses. An overall performance score was calculated by summing the scores across all ten items, yielding a total score ranging from 0 to 10, with higher scores indicating better performance. To further characterize performance across specific skill areas, average domain scores were computed for each of the five TMD domains, ranging from 0 (least accurate response) to 1 (most accurate response). Details regarding the TMD diagnoses and competencies assessed in each case scenario for both pre- and post-intervention assessments are provided in Supplemental File 1.

2.4.2. Change in self-perceived knowledge.

Self-perceived knowledge was assessed at post-intervention using a retrospective pre/post survey. The retrospective pre/post approach is commonly used in educational research to minimize response-shift bias and reduce over/underestimation of baseline competence prior to content exposure.^{25, 26} The six-item questionnaire assessed knowledge related to TMD history taking, recognition of signs and symptoms of arthrogenous and muscular TMD, first-line and self-care TMD management strategies, and differentiation between true TMD and non-TMD conditions. The items were selected from a previous study assessing educational outcomes of a TMD-specific digital curriculum.²⁷ Answer options ranged from 1 (“None, I have no knowledge of the content”) to 4 (“High, I consider myself very knowledgeable”), with higher scores indicating greater self-perceived knowledge.

2.4.3. Confidence level in TMD-related skills.

At the conclusion of the post-intervention assessment, participants’ self-perceived confidence in TMD-related skills was measured using a previously validated 12-item questionnaire.¹⁰ Responses were recorded on a 0–10 numerical rating scale, with higher scores reflecting greater confidence. Items assessed confidence in TMD screening, differentiating TMD pain from odontogenic pain, establishing TMD diagnoses and treatment needs, patient education regarding etiological factors and diagnosis, occlusal appliance adjustment, performance of diagnostic injections, management of TMD, and interprofessional communication related to TMD care.

2.5. Sample Size

The study was conducted as a census of the fourth-year dental class at the Adams School of Dentistry, University of North Carolina. All students enrolled in the course completed the pre- and post-intervention assessments. No formal sample size calculation was performed, as the study aimed to include all students in the target population. A post-hoc power analysis, based on the observed pre-post differences in TMD performance scores, suggested that this sample provides adequate power (>0.99) to detect a statistically significant change using a paired t-test at a 0.5 significance level.

2.6. Statistical Methods

Descriptive statistics were used to summarize the total sample, with continuous variables presented as means and standard deviations and categorical variables as frequencies and percentages. Normality of continuous variables was assessed with Shapiro-Wilk tests.

To test the primary aim, one assessor (orofacial pain specialist, dental educator, and ABOP board-certified) independently scored each pre- and post-assessment based on a predefined rubric. To reduce the risk of assessment bias, responses were de-identified and randomly ordered before evaluation, and the assessor was blinded to the timing of the assessment (pre- vs post-intervention). Paired-sample t-tests for normally distributed data (and Wilcoxon signed-rank test for non-parametric data) were used to compare pre- and post-intervention scores for overall performance on diagnostic and management skills, and across each TMD domain. Effect sizes were computed using Cohens’ d for parametric tests and r for nonparametric tests and interpreted according to conventional thresholds, where values of 0.2, 0.5, and 0.8 indicated small, medium, and large effects, respectively for Cohen’s;²⁸ values of 0.1, 0.3, and 0.5 indicated small, medium, and large effects, respectively for r.²⁹

To test the secondary aim, Wilcoxon signed-rank tests for ordinal data was used to compare changes in self-perceived knowledge scores between pre- and post-intervention. Pearson correlation coefficient was used to examine the correlation between post-intervention knowledge scores and self-perceived confidence levels.

To evaluate the tertiary aim, an overall confidence index was calculated as the average of the 12 items and compared to a predetermined cut-off of 5 (i.e., 50% of the maximum score on the 0–10 scale), identified as sufficient confidence according to prior literature.¹⁰ The proportion of participants meeting this threshold was reported descriptively and no formal inferential test was applied.

A two-tailed p-value of <0.05 was considered statistically significant. Statistical analyses were conducted with SPSS (v31, IBM Corp., Armonk, NY).

3. Results

The full cohort of fourth-year dental students (N=83, 100%) completed both the pre- and post-intervention assessments (Figure 3).

Figure 3.

Flowchart of study participants.

Performance on TMD diagnostic and management skills

Comparing to baseline, after the intervention there was a statistically significant increase in overall performance, with scores increasing by 1.1 point on a 0–10 scale (8.29±1.40 vs. 9.40±0.83, Z=−5.46, p<0.001, r=0.64). Significant improvements were observed across all TMD-related domains (Figure 4), including diagnostic accuracy (0.75±0.16 vs. 0.84±0.26, p=0.006), diagnostic reasoning (0.77±0.30 vs. 0.95±0.16, p<0.001), appropriateness of management (0.84±0.19 vs. 0.96±0.07, p<0.001), justification for additional testing (0.84±0.26 vs. 0.98±0.09, p<0.001), and understanding of systemic/local factors influencing TMD diagnosis (0.83±0.20 vs. 0.92±0.31, p=0.040).

Figure 4.

Change in performance in TMD-related skills.

*significant at p<.05; **significant at p<.001.

Self-reported confidence levels and knowledge in TMD-related skills

At the end of the final assessment, a cohort of 56 participants (67.5%) provided their responses on self-perceived confidence and knowledge, with 40 (71.4%) completing all items (Figure 3).

Self-perceived knowledge in TMD-related skills improved significantly at post-intervention (2.6±0.7 vs. 2.9±0.6, Z=−3.91, p<0.001, r=0.70). Specifically, significant increase was observed in conducting a TMD history (2.7±0.9 vs. 3.0±0.8, p=0.003), recognizing signs and symptoms of common arthrogeneous (2.5±0.9 vs. 2.8±0.8, p=0.003) and muscular (2.6±0.8 vs. 2.8±0.8, p=0.003) TMD diagnoses, and differentiating between true TMD and non-TMD (2.2±0.9 vs. 2.7±0.8, p<0.001). Conversely, self-perceived knowledge in first-line TMD management (2.8±0.9 vs. 2.9±0.7, p=0.165) and self-care strategies (2.8±0.9 vs. 3.0±0.7, p=0.197) did not significantly improve post-intervention (Figure 5).

Figure 5.

Change in self-perceived knowledge in TMD-related skills between pre-post intervention.

*significant at p<.05; **significant at p<.001.

Overall confidence in TMD-related skills was moderate (5.3±1.7). The highest confidence was reported for differentiating TMD pain from dental pain (7.1±2.1), whereas performing diagnostic injections to confirm TMD diagnosis had the lowest confidence score (3.1±2.6, Figure 6). Nearly two-thirds (61.1%) of participants achieved a sufficient confidence level (i.e., confidence index ≥5 on 0–10 scale).

Figure 6.

Confidence levels in TMD-related skills.

Post-intervention knowledge scores positive correlated with confidence levels (r(36)=.700, p<0.001).

4. Discussion

This study evaluated the impact of a VPBL educational intervention on dental students’ TMD-related diagnostic and management skills. Consistent with our primary hypothesis, exposure to the VPBL platform resulted in significant improvements in overall performance on OSCE-style case assessments, with gains observed across all evaluated domains. These findings align with prior work demonstrating persistent gaps in TMD education among dental trainees^{9, 14} and support the use of repeated, structured and standardized case-based practice to address deficiencies in clinical preparedness for TMD.

Educational impact on diagnostic and management performance

The observed improvements in diagnostic accuracy, diagnostic reasoning, and management decision-making suggest that structured and repeated virtual patient exposure can meaningfully augment traditional didactic instruction by reinforcing theoretical concepts and bridging the gap to clinical practice. TMD predoctoral dental curricula often rely heavily on lectures, with limited opportunities for experiential learning, contributing to variable competence among graduates.^{10, 30} Case-based and simulation-based learning approaches enhance clinical reasoning and applied performance, particularly for complex and heterogeneous diagnostic conditions with limited clinical exposure.^31–33 In this study, improvements were most pronounced in diagnostic reasoning and justification for additional testing, skills that require synthesis of patient history, examination findings, and contextual factors. This is clinically relevant, given the high rates of TMD misdiagnosis in general dental practice.³⁴

Educational research has shown that direct patient exposure enhances diagnostic, management skills, and knowledge retention; one study found that learners with clinical exposure had more than three times the odds of demonstrating sufficient TMD-related knowledge compared with those without such exposure.⁹ However, predoctoral education often lacks sufficient or standardized TMD patient exposure, leading to variability in competence. VPBL platforms may help address these gaps by providing consistent clinical exposure to key conditions aligned with DC/TMD and ICOP frameworks, allowing students to practice critical reasoning in a controlled environment.

Confidence and self-perceived knowledge

Self-perceived knowledge improved significantly following the intervention, particularly in history taking and differentiation of TMD subtypes, consistent with prior studies demonstrating the value of TMD-specific virtual learning environments in replicating history taking and orofacial pain interviews through autonomous virtual patients.^35–37 Despite statistically large effect sizes, gains were smaller than those reported in other digital curricula, such as that described by Hawkins et al., that also incorporated structured didactic content.²⁷ This 5-hour, four-module course demonstrated promising results in knowledge, perceived competence, and clinical applicability among 30 clinicians.²⁷ Contrary to our findings where pre- to post-intervention changes in self-perceived knowledge ranged from 0.2 to 0.5 on a 1–4 scale, Hawkins et al. reported improvements of ~1.4 to 1.5 across comparable domains. Several factors may explain these differences. Participants in the study by Hawkins et al. had lower baseline knowledge scores (ranging from 1.8 to 2.1) compared with our cohort (from 2.2 to 2.7), likely reflecting limited prior exposure to TMD didactic content. In our program, students had already received foundational instruction before the intervention, potentially constraining the magnitude of measurable change. Additionally, higher post-intervention scores in Hawkins et al. (3.3–3.5 vs. 2.7–3.0 in our cohort) may reflect the immediate clinical relevance of the content for practicing clinicians or possible selection bias related to snowball sampling, whereas the present study included the entire class of students.

Consistent with our findings, Trivedi et al. demonstrated the educational value of virtual patients in developing diagnostic reasoning and clinical decision-making skills in TMD.³⁷ Their study showed that diagnostic accuracy was the strongest predictor of overall performance, underscoring the importance of repeated practice in virtual environments to reinforce diagnostic skills.³⁷ This supports the utility of digital learning platforms not only to enhance students’ ability to obtain an accurate diagnosis, but also to strengthen subsequent clinical decisions, including appropriate diagnostic testing and treatment planning.

Prior work has demonstrated a positive association between TMD-related knowledge and self-perceived confidence among dental students and early-career providers, supporting the relevance of targeting both domains in educational interventions.^{21, 38} Despite objective performance gains, overall confidence remained moderate at post-intervention, with about two-third of participants achieving sufficient confidence levels. The lowest confidence domain was reported for advanced procedures such as diagnostic injections. This finding is consistent with prior literature indicating that advanced or invasive TMD procedures are generally considered beyond the scope of predoctoral training and routine general dental practice, with educational emphasis placed on conservative management and referral.^{14, 39–42} Importantly, educational literature emphasizes that confidence should be appropriately calibrated to competence and scope of practice, as overconfidence without sufficient skills may negatively impact patient care.⁴³ In addition, the current version of the VPBL did not include any specific educational modules on diagnostic injections, which were only listed among the evidenced-based management options for myofascial pain diagnoses. Future amendment to the VPBL should incorporate educational videos showing procedural steps on how and when diagnostic injections should be performed. Self-perceived knowledge related to first-line management and self-care strategies did not significantly improve, a finding that has been observed in prior TMD educational studies and may reflect a ceiling effect or the need for repeated clinical reinforcement to translate management principles into practice.¹⁰

Alignment with the ORBIT framework and implications for intervention refinement

For the first time, the development and evaluation of an educational intervention were guided by the ORBIT model, a phase-specific and progressive framework designed to optimize behavioral interventions that ultimately lead to meaningful improvements in chronic disease outcomes.¹⁹ In this framework, dental students represent the intermediate target, and improvements in diagnostic accuracy, clinical reasoning, and management decision-making constitute key behavioral outcomes that function as mediators preceding downstream improvements in patient care. Accordingly, the present study aligns with ORBIT Phase Ib (Refine), which, in the context of educational interventions, specifically emphasizes testing these intervention-specific mediators as the mechanisms through which the intervention is hypothesized to exert its effects toward the ultimate clinical target. Assessment of post-intervention confidence and knowledge according to pre-specified thresholds aligns with the ORBIT Phase I framework, which emphasizes evaluating the feasibility and initial impact of an educational intervention. Demonstrating meaningful gains across multiple behavioral domains supports progression of the VPBL intervention to subsequent ORBIT phases, including further refinement and large-scale efficacy testing.¹⁹ The observed dissociation between objective performance and confidence highlights an opportunity for future iterations of the platform to incorporate reflective practice, guided feedback, or integration with supervised clinical experiences, approaches that have been shown to support deeper learning and facilitate application of skills across health professions education.^{44, 45}

Strengths and limitations

This study has several strengths, including a full-cohort design with complete pre- and post-intervention performance data, use of OSCE-style assessments scored by a board-certified orofacial pain specialist, and evaluation of both objective and subjective educational outcomes.

Limitations should also be acknowledged. The single-group, pre-post design precludes causal inference and does not control for maturation or testing effects. The study was conducted at a single institution, which may limit generalizability to other dental schools with different curricular structures. Confidence and self-perceived knowledge data were available for a subset of participants, introducing potential response bias. De-identified assessments were evaluated randomly using a pre-defined rubric by a single reviewer who was blind to the timing of the assessment. Nevertheless, differences in the cases at both timepoints could have allowed the reviewer to infer whether an assessment occurred before or after the intervention. Moreover, the use of different OSCE-style cases scenarios for pre- and post-intervention assessments, which was necessary to avoid recall bias and to better assess knowledge acquisition, may have introduced variability in case difficulty and influenced performance outcomes. Approximately 68% of participants completed the self-reported confidence and knowledge assessment. While this represents the majority of the cohort, responses may reflect students who were more engaged or motivated, potentially introducing response bias. Finally, while improved performance on simulated cases is encouraging, future studies should examine whether these gains translate into sustained knowledge retention, improved clinical behaviors, and patient-centered outcomes.

Conclusions and future directions

Integrating a TMD-specific VPBL platform into predoctoral dental education was associated with significant improvements in diagnostic and management performance and modest gains in self-perceived knowledge and confidence. These findings support the use of virtual patient simulations as a scalable and effective strategy to address gaps in TMD education and clinical exposure. Future research should evaluate longitudinal outcomes, compare VPBL with alternative educational modalities, and assess implementation across diverse dental education settings. Ultimately, enhancing provider-level competencies through innovative educational approaches represents a critical step toward improving the recognition and management of TMD in clinical practice.