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. 2025 Apr 30;59(6):929–942. doi: 10.1111/iej.14246

Outcomes of root canal treatment performed by undergraduate students: A systematic review and meta‐analysis

Philip Y‐H Chien 1, Sepanta Hosseinpour 1, Ove A Peters 1,✉, Christine I Peters 1,2
PMCID: PMC13158552  PMID: 40304173

Abstract

Background

The outcomes of root canal treatment performed by students has not been well researched. Treatment outcomes of student clinicians directly correspond to the education they receive and therefore paves the way for future directions in endodontic education.

Objectives

This systematic review aimed to evaluate endodontic outcomes and success rates of contemporary root canal treatment delivered by undergraduate dental students. Factors with a positive or negative effect on endodontic education and clinical treatment quality were evaluated.

Methods

The investigation followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Studies from 2000 to 2024 were selected from PubMed, Scopus, Cochrane Library and Embase databases after applying inclusion and exclusion criteria. Each study was independently assessed, and bias was categorized systematically as low, moderate or high using the risk of bias (RoB) assessment tool. Unweighted and weighted pooled success rates for each factor were calculated, and statistical heterogeneity among study subgroups was evaluated.

Results

Eleven studies were eligible for data extraction and qualitative synthesis. Three studies were eligible for meta‐analysis and showed that teeth diagnosed with a vital pulp had a success rate of 87.8%, while teeth diagnosed with pulp necrosis had a success rate of 65.6%. Weighted success rates for teeth with and without preoperative radiolucencies were 56.3% and 86.8%, respectively. The RoB assessment showed that 4 out of 11 studies (36.4%) had a low risk of bias.

Conclusions

The outcomes of root canal treatment performed by undergraduate students using contemporary techniques are not well understood. This analysis demonstrated that while student clinic outcomes were comparable to those reported in contemporary literature for general and specialist practice, variations in success rates may be influenced by factors such as clinical experience, exposure to diverse cases and teaching methodologies. Further research is needed to explore how educational innovations and clinical training impact endodontic outcomes in undergraduate settings.

Registration

The systematic review search protocol was registered in the PROSPERO database (CRD42024604079).

Keywords: dental education, healing outcomes, root canal treatment, student clinics, systematic review

INTRODUCTION

Endodontics is a discipline of clinical dentistry that aims to preserve the function of natural dentition via the prevention and resolution of apical periodontitis (Ørstavik, 2019). In undergraduate endodontic curricula, demonstrative teaching allows students to gain competency in nonsurgical root canal therapy on patients. Detailed learning objectives and expected skillsets have been published previously, such as the guidelines provided by the European Society of Endodontology (Baaij et al., 2024; De Moor et al., 2013) and the Australian Society of Endodontology (Sadr et al., 2021). Established guidelines serve as a benchmark of minimum requirements and level of competence for graduating dentists. This is important, as the majority of endodontic procedures will continue to be treated by general dental practitioners rather than endodontic specialists (De Moor et al., 2013).

Teaching clinical endodontics primarily involves direct supervision of students in a clinical setting. In most dental schools, supervision is provided by either endodontists, post‐graduate residents in endodontics or general dentists with an interest in endodontics. Unsurprisingly, the quality of teaching may vary globally depending on the rate of adoption of new technology and techniques, treatment philosophy, the availability of specialist supervisors, and the time spent in pre‐clinical and clinical training (Dummer, 1991).

The evaluation of undergraduate endodontic teaching provides valuable insights in a constantly evolving field and continues to be an important subject of interest. Multi‐national survey studies showed significant variations in the course design, equipment, access to technology, staff‐to‐student ratio, hours spent pre‐clinically and clinically (Nagendrababu et al., 2024; Segura‐Egea et al., 2021). However, the effectiveness of endodontic education is difficult to assess, and little is known about the impact of different approaches to teaching endodontics in dental schools. A previous study used Kirkpatrick's four‐level training evaluation model (Kirkpatrick & Kirkpatrick, 2006) to assess learning outcomes, but the context of the study assessed simulation learning which does not directly correlate with clinical performance.

A more recent consideration in clinical teaching is the goal of self‐efficacy, in other words, the belief and self‐assurance that, despite the prevailing circumstances, a practitioner will be able to perform specific tasks successfully (Baaij et al., 2024). Achieving self‐efficacy is dependent on competence, demonstrated in clinical outcomes. It remains to be seen that innovative teaching and contemporary clinical techniques are associated with good outcomes in the undergraduate student clinic.

Clinical outcomes in endodontics may be benchmarked in three ways: technical quality of root canal treatment, patient‐reported outcomes and clinician‐reported treatment outcomes. Quality assessment of nonsurgical root canal treatment has been extensively studied and involves examination of radiographic obturation criteria, including length of root filling, density of obturation, presence of voids and sealer extrusion (Habib et al., 2018; Khabbaz et al., 2010; Lin et al., 2022; Mousa et al., 2022; Silvani et al., 2013). Such studies are comparatively simple to perform via a retrospective analysis of a radiographic data set and can be useful in identifying the gaps in learning from an educational standpoint.

However, assessment of treatment quality alone may not deliver meaningful data from a patient‐centred perspective. The classic concept of ‘cognitive dissonance’ illustrates this point: a poorly obturated root canal treatment does not automatically lead to treatment failure; vis‐à‐vis, a well obturated root canal treatment does not imply treatment success either (Seltzer & Bender, 1965). Recently, there has been growing interest in patient‐reported outcomes, with measures such as oral health‐related quality of life (OHRQOL) parameters (Wong et al., 2024) and the oral health impact profile‐14 (OHIP‐14) (Wen et al., 2024) being used as alternative methods to assess treatment success. Although patient perception is an important dimension to consider, such metrics do not allow for an objective assessment of students' treatment success rates.

Ultimately, what is pertinent is the clinician‐reported treatment outcome, which is determined by specific clinical and radiographic criteria to judge the validated surrogate or real clinical endpoint (Duncan et al., 2021). In other words, ‘has treatment resolved the disease?’. Endodontic outcome studies have also been comprehensively published, some of which form the contemporary understanding of clinician‐reported endodontic treatment success rates (Burns et al., 2022; Friedman et al., 2003; Gulabivala & Ng, 2023; Ng et al., 2007).

The present study aims to perform a systematic review on endodontic outcomes of undergraduate students to understand success rates when root canal treatment is performed by beginner clinicians. In addition, an evaluation of any factors that may have a positive or negative effect on endodontic education and clinical treatment quality of undergraduate dental students that are decisive in improving dental education is also performed.

MATERIALS AND METHODS

Reporting guidelines and protocol registration

The Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines were followed for the purposes of the systematic investigation (Page et al., 2021). The protocol for the proposed study was developed and registered in the PROSPERO database (CRD42024604079), as seen in the chart in Figure 1.

FIGURE 1.

FIGURE 1

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The PRISMA flow chart of the literature search strategy and included studies. The details of the steps and the number of records identified, screened, excluded, reasons for exclusions and ultimately included in the review are specified.

Literature search strategy

Two reviewers (P. C.; S. H.) conducted a systematic search of several electronic databases included PubMed, Scopus, Cochrane Library and Embase focusing on articles published from 2000 to the present. Keywords included: “root canal treatment” OR “endodontic treatment” OR “root canal sealant” OR “root canal filling” AND “treatment outcome” OR “outcome” OR “outcomes” OR “clinical competency”. The literature search strings utilized are listed in Table S1. Comprehensive inclusion and exclusion criteria can be found in Table 1.

TABLE 1.

Inclusion and exclusion criteria used for the systematic search.

Inclusion criteria Exclusion criteria
Language English only N/A
Population (P)

Patients that received treatment on permanent teeth treated by undergraduate or pre‐doctoral students

Patients of all age, gender, health groups

All types of permanent dentition

Patients that received treatment from post‐graduate students, general dental practitioners or endodontists

Patients that received treatment on their deciduous dentition

Studies with animal and microbiological studies
Intervention (I) Primary nonsurgical root canal treatment (NS‐RCT) or nonsurgical retreatment (RE‐TX) in permanent teeth Other forms of endodontic treatment
Comparison (C) N/A N/A
Outcomes (O) Treatment outcomes which must include clinician‐reported radiographic and clinical assessment Alternative measures of outcomes such as patient‐reported outcomes (quality of life metrics, surveys) and technical quality assessment of treatment
Study types (S) Randomized control trials (RCT), retrospective, prospective, cross‐sectional and cohort studies Systematic and narrative reviews, meta‐analyses, case reports
Other N/A Studies with insufficient clinical data for extraction
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Selection of studies

All retrieved studies were imported into EndNote 20 (Clarivate Analytics, Philadelphia, PA, USA) and Covidence (Covidence, Melbourne, Australia) for assessment by the primary reviewers. Duplicates were removed automatically by the in‐built feature in Covidence or manually when required. Title and abstract screening and full‐text review were performed individually by the two reviewers, with any disagreements resolved by a third reviewer (C.P.).

Data extraction process

All the relevant clinical parameters modified from Ng et al., 2007 were extracted for the selected studies (Ng et al., 2007). The extracted information is as follows:

  1. Author, date and geographic location of study.

  2. Study type.

  3. Teeth treated (sample size, type of teeth).

  4. Technique (number of visits, instrumentation, irrigation and obturation techniques).

  5. Follow‐up periods and recall rates.

  6. Preoperative pulp and periapical status.

  7. Success criteria.

  8. Overall success rate given or could be calculated from the raw data.

Risk of bias assessment

The risk of bias (RoB) assessment was conducted using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross‐Sectional Studies (Munn et al., 2020) to evaluate the cross‐sectional studies included in this review. For the sole randomized controlled trial (RCT) included, the RoB2 Cochrane checklist was applied (Sterne et al., 2019). The JBI checklist examines key domains, such as the clarity of inclusion criteria, validity of exposure and outcome measurements, control of confounding factors and suitability of statistical analyses.

Each study was independently assessed, and the risk of bias was categorized systematically as low, moderate or high. For the RCT studies, the RoB2 tool considers low risk of bias if only one out of five domains' rates moderate, moderate risk if two domains rate moderate and high risk if three or more domains rate high risk.

Statistical analysis

All statistical analyses were conducted using RevMan version 5.2 (The Cochrane Collaboration, Copenhagen, Denmark) for Windows. Unweighted pooled success rates for each factor were calculated by dividing the total number of successful cases by the total number of cases (excluding uncertain cases) within the corresponding category, following the method described by Hepworth and Friedman (1997). Weighted pooled success rates were determined through a random‐effects meta‐analysis using the DerSimonian and Laird method (DerSimonian & Laird, 2015). Statistical heterogeneity among study subgroups was evaluated using Cochran's Q test (Cochran, 1954). Factors extracted included demographics, teaching staff, tooth numbers and characteristics, treatment techniques, and methods of clinical and radiographic success or failure assessment. Comparable data were pooled for meta‐analysis, and risk difference analysis was performed to quantify the absolute difference in success rates between studies.

RESULTS

Selection of studies

The PRISMA flow chart of the literature search strategy and selected studies for this review is shown in Figure 1. In summary, a total of 2069 studies were extracted from the databases. After removing duplicates (n = 838), a total of 1231 studies were eligible for title and abstract screening. Full‐text screening was performed for 63 studies, which resulted in 11 eligible studies for review.

Data analysis

The extracted data from the 11 selected studies can be found in Table 2. Ten of the 11 studies (90.9%) were retrospective observational studies, with one CONSORT randomized controlled trial (RCT). Outcomes associated with root canal treatments by undergraduate students from the USA, Brazil, Malaysia, Thailand and Greece were observed. Regarding teaching staff, students were supervised by either endodontic faculty members or endodontists.

TABLE 2.

Characteristics of the included studies.

Author Location Study design Teeth treated Technique Follow‐up Assessment criteria Supervisor Preoperative status Restoration assessment at follow‐up
Sample size Teeth type No. of visits Instrumentation Irrigation Obturation Post‐op recall Recall rate (%) Preop pulp diagnosis Preop periapical diagnosis
Pettiette et al. (2001) USA RO 60 Molars NM H No information No information 1 yr 66.0 No information No information No information No information No
De Quadros et al. (2005) Brazil RO 579 All types Single or multiple visits H 1% NaOCl, 1%NaOCl +17% EDTA, 1%NaOCl +2.0% CHX gel LC 1 and 3 yr

1 yr: 30.7

3 yr: 8.0

 S Endodontist Yes Yes Yes
Azim et al. (2016) USA RO 291 All types Multiple visits R 3–6% NaOCl + EDTA LC 6 month – 8 yr No information L Endodontist Yes Yes No
Polyzos et al. (2018a) Greece RO 244 All types Multiple visits H 2.5% NaOCl LC 2–5 yr 31.4 L Faculty member Yes Yes Yes
Polyzos et al. (2018b) Greece RO 244 All types Multiple visits H 2.5% NaOCl LC 2–5 yr 31.4 L Faculty member Yes Yes Yes
Cunha et al. (2020) Brazil RCT 75 Molars Multiple visits H & R 2.5% NaOCl, 17% EDTA Single cone 1–2 yr 92.0 Not clear Faculty member No No Yes
Daud Ibrahim et al. (2021) Malaysia RO 175 No information No information No information NaOCl and EDTA used. % undisclosed. No information 6 months – 4 yr No information S & L No information No No Yes
Chaisophin et al. (2022) Thailand RO 176 Anterior and pre‐molar Multiple visits H 2.5% NaOCl, 17% EDTA, normal saline, 2% CHX LC 6 months – 5 yr 31.7 S Endodontist Yes Yes Yes
da Rocha et al. (2022) Brazil RO 91 All types Multiple visits H 1 or 2.5% NaOCl LC 3–8 yr 92.3 S No information No No Yes
Mohammad et al. (2023) Malaysia RO 143 All types Multiple visits H 3% NaOCl LC 1–6 yr 55.0 S Endodontist and restorative specialist Yes Yes Yes
Wen et al. (2024) Malaysia RO 226 All types, no second or third molars Multiple visits H & R 2% NaOCl, 17% EDTA LC 1–5 yr 28.2 S Endodontist Yes Yes Yes
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Abbreviations: CHX, chlorhexidine; EDTA, Ethylenediaminetetraacetic acid; H, hand instrumentation; L, loose criteria; LC, lateral condensation; R, rotary instrumentation; RCT, randomized clinical trial; RO, retrospective observational; S, strict criteria; yr, year.

The number of teeth examined in each study ranged from 60 to 579, with a mean of 171.4 teeth. All tooth types (incisors, pre‐molars and molars) were treated by the undergraduate students.

Treatment techniques varied considerably for instrumentation, irrigation and obturation. Only 2 of the 11 studies (18.2%) incorporated the use of rotary instrumentation (Azim et al., 2016; Wen et al., 2024). The concentrations of sodium hypochlorite (NaOCl) used ranged from 1 to 6%. Only 6 studies (54.5%) specified the use of ethylenediaminetetraacetic acid (EDTA) and 2 studies (18.2%) utilized chlorhexidine (CHX) in the irrigation protocol. Obturation techniques consisted mostly of lateral condensation techniques (72.7%), with one reported study using a single obturation technique (9.1%). Postoperative recall periods ranged from 6 months to 8 years, with recall rates ranging from 8.0% to 92.3%. Nine out of the 11 studies (81.8%) included an assessment of the restoration at follow‐up.

Methods of assessments in the included studies

Both clinical and radiographic studies assessments were used to determine success in all selected studies. The selected studies incorporated many different radiographic criteria of success, but overall, they could be categorized into ‘strict’ (complete resolution of periapical lesion at postoperative recall) and ‘loose’ (reduction in size of existing periapical lesion at postoperative recall). Examples of strict criteria included the 1994 European Society of Endodontology guidelines and criteria discussed by Ng et al.  2011). Ørstavik's periapical index (PAI) was one of the methods of determining changes in periapical radiolucencies (Ørstavik et al., 1986). Clinical assessments also varied from study to study: Parameters included absence of pain on percussion, swelling, inflammation, sinus tract or increased mobility to determine success.

Clinical and radiographic success rates

Figure 2 depicts the success and failure rates of endodontic treatment from 11 individual studies, along with the associated risk differences and their 95% confidence intervals The overall pooled risk difference is 0.43 [95% CI: 0.40, 0.46], indicating a significantly higher likelihood of a successful treatment outcome. The individual studies show varying risk differences, ranging from 0.12 (da Rocha et al., 2022) to 0.76 (Cunha et al., 2020). The forest plot reveals considerable heterogeneity (Chi2 = 135.30, p < .00001; I 2 = 93%), suggesting variability in study outcomes, possibly influenced by differences in methodology, patient factors or treatment protocols. Despite this heterogeneity, the overall effect size is highly significant (Z = 30.91, p < .00001).

FIGURE 2.

FIGURE 2

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Weighted pooled success rates and individual study weights. The sample sizes and pooled success rates alongside the names and publication years of the individual studies are displayed. The risk difference corresponds to the success rate, representing the proportion of successful outcomes both overall and for each individual study.

The weighted pooled success rates, derived from a random‐effects meta‐analysis, provide a more nuanced understanding of treatment outcomes compared with the unweighted rates. Success rates were notably greater for teeth with vital pulps (87.8%) compared with necrotic pulps (65.6%). Similarly, teeth without preoperative periapical lesions demonstrated higher success rates compared to those with and without preoperative radiolucencies (86.8% vs. 56.3%). Anterior and pre‐molar teeth showed greater success rates than molars (82.2% and 79.4% vs. 68.7%), which may reflect the complexity of molar anatomy. Furthermore, success rates varied slightly based on arch location.

Risk of bias

The risk of bias for the 11 clinical studies included in this review was evaluated using the JBI framework (Munn et al., 2020) and the RoB2 tool (Sterne et al., 2019), and the results are detailed in Table 2. Only 4 out of 11 studies (36.4%) were found to have a low risk of bias, as displayed in Figure 3. These studies primarily focused on assessing the outcomes of primary nonsurgical endodontic treatment performed by dental students. Additionally, some studies explored the influence of different factors on treatment outcomes, such as irrigation methods (De Quadros et al., 2005), systemic conditions (Azim et al., 2016) and types of sealers (Cunha et al., 2020). One study (9.1%) was categorized as a high risk of bias, while six studies (54.5%) were of moderate risk of bias. The main limitations observed were unclear preoperative pulp and periapical diagnoses, lack of information on tooth types included and inconsistent outcome assessment criteria.

FIGURE 3.

FIGURE 3

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Risk of bias graph. Each risk of bias item is presented as a percentage across all included clinical studies. The criteria are divided into low, medium and high risk of bias where low = meeting 75% or more of the checklist criteria; moderate = meeting between 50% and 74% of the checklist criteria and high = meeting <50% of the criteria.

DISCUSSION

This systematic review and meta‐analysis aimed to assess the present status of root canal treatment performed by undergraduate dental students. Following Preferred PRISMA guidelines, data from 11 studies that met the specified inclusion criteria were assessed, and the risk of bias was categorized systematically as low, moderate or high. This rigorous process ensured consistent and transparent evaluation, improving the reliability of the findings and interpretations presented in the review.

Students are novice clinicians performing root canal therapy under the supervision of either a dentist, post‐graduate endodontic resident or endodontist. One could reasonably predict that the outcome of treatment by a student with minimal experience performing a procedure would be inferior to that of an experienced clinician or specialist. It is also reasonable to postulate that the clinical performance of undergraduate students would be directly influenced by the quality of education, including various innovative approaches. However, so far, there exists no study to address these assumptions.

Several previous studies have assessed the technical quality of students' root canal treatment, assessed based on radiographs (Abu‐Tahun et al., 2014; Donnelly et al., 2017; Elsayed et al., 2023; Fong et al., 2018; Habib et al., 2018; Lin et al., 2022; Mayhew et al., 1999; Mousa et al., 2022; Moussa‐Badran et al., 2008; Vukadinov et al., 2014). The methodologies in these studies primarily involved a retrospective analysis of post‐obturation periapical radiographs, using parameters such as obturation length, density, taper or presence of procedural errors to determine treatment quality. Such studies are simple and cost‐effective and can be used as a form of clinical audit for teaching institutions, particularly in understanding the incidence of complications. However, the relationship between the precise technical execution and treatment outcome has recently been addressed, and the association between the two domains is both poorly understood and likely overestimated (Gulabivala & Ng, 2023).

Further, postoperative radiographs alone are only a surrogate measure of the entire treatment process as it cannot account for the quality of the cleaning and shaping process. Most importantly, technical assessment studies do not assess the impact of treatment on the patients in terms of clinical resolution of disease. Although the quality of the obturation is an important factor and predictor of treatment success (Ng et al., 2008; Sjogren, 1990), the analysis of obturation alone is an inadequate representation of clinical outcomes.

Variations in treatment protocol

Based on the inclusion of studies published after the year 2000, the assumption was that contemporary clinical methods were employed in undergraduate root canal treatment. However, while this may be true, there was no specific treatment protocol among the identified studies. Instrumentation technique varied: manual step‐back and crown‐down techniques, rotary instrumentation or a combination of the three. Moreover, as the majority of the studies were retrospective studies, and there were reported observation times of up to 8 years, the information relied on older clinical data that followed earlier endodontic philosophies. The geographical locations of the studies could account for differing access to certain instruments. Unsurprisingly, the more contemporaneous studies by Azim et al., Cunha et al. and Wen et al incorporated the use of rotary instrumentation (Azim et al., 2016; Cunha et al., 2020; Wen et al., 2024). The uptake of rotary endodontic instruments could affect student performance, as a recent systematic review demonstrated that rotary instrumentation reduced preparation time, resulted in a smaller change of the canal curvature than manual instruments and presented better results regarding root canal transportation, ability of centralization within the canal path and shaping of the canal (Peralta‐Mamani et al., 2019). It remains to be seen if, at the individual institution level, further developments in technology will change patient outcomes over time.

Irrigation protocols varied in terms of the type of irrigant and its concentration, corresponding to similar findings by Gulabivala et al.'s study when qualified dentist outcomes were analysed (Gulabivala & Ng, 2023). Although chemical disinfection via irrigation is important in the cleaning and shaping of canals, so far, no study has advised the optimal concentration of NaOCl or EDTA. Recent guidelines and expert consensus statements have shown that concentrations of NaOCl exist from 0.5% to 8.25% (Peters et al., 2024; Zou et al., 2024), but the relationship between irrigant concentration and treatment outcome remains unelucidated (Gulabivala & Ng, 2023).

Obturation was accomplished mostly via the lateral condensation technique, which could be explained by the traditional teaching philosophies that paired with manual instrumentation and by the necessity to initially teach a comparatively simple ‘gold standard’ technique that does not require additional devices unfamiliar to novices. Only one study used a single cone obturation technique (Cunha et al., 2020) which had conform‐fit gutta percha points to match the rotary instrumentation. All studies used epoxy resin‐based sealers for obturation except one study (De Quadros et al., 2005) that used endomethasone instead. None of the studies utilized calcium silicate‐based sealers. Presently, there is no superior obturation type and it is unlikely to be a major factor for different treatment outcomes among the selected studies (Pirani & Camilleri, 2023).

Variations in outcome assessment

Outcome assessment can be accomplished from the viewpoints of technical quality of root canal treatment as assessed radiographically, of patient‐reported outcomes as determined by absence of or improvement of clinical symptoms and tooth retention as well as from clinician‐reported treatment outcomes, which are based on certain criteria. While the focus of this review was not to compare all possible assessment criteria, it should be noted that a combination of radiographic and clinical evaluations determined success in the selected studies. Clinical assessments differed between studies and included parameters such as absence of pain on percussion, swelling, inflammation, sinus tract or increased mobility. Radiographic criteria of success ranged from ‘strict’ (complete resolution of any periapical lesions) to ‘loose’ criteria (size reduction of periapical lesions) (Endodontology 1994; Ng et al., 2011). The length of follow‐up was between 6 months and 8 years and included inspection of the restoration in the majority of teeth.

Outcome determination criteria varied widely, with multiple forms of radiographic and clinical criteria utilized. Earlier studies devised their own methodology of assessment such as a ratio of the periradicular area compared with the normal area—the so‐called ‘AP/N’ ratio (Pettiette et al., 2001). The periapical index (PAI) was used by a few studies in the postoperative radiographic assessment (Chaisophin et al., 2022; Mohammad et al., 2023; Polyzos et al., 2018a, 2018b), but not all studies were clear about how the index was used. The key clinical determinants of success were similar across the studies, which were the absence of pain, swelling and other symptoms, no sinus tract and no loss of function (Endodontology 1994). A detailed summary of the types of outcome assessment used can be found in Table S2.

Dental students' treatment success rates

The weighted success rates from the three studies eligible for meta‐analysis showed that vital teeth had a success rate of 87.8%, and necrotic teeth had a success rate of 65.6%. Similarly, weighted success rates for teeth with no preoperative lesions were 86.8% and teeth with preoperative lesions were 56.3% (Table 3). These results do not differ significantly from experienced clinicians such as post‐graduate endodontic residents who listed a range of 74.3–100% for teeth with vital pulps and 73.8–83.7% for teeth with necrotic pulps (Ng et al., 2007). A possible reason for the similarity in success rates despite operator experience could be attributed to the fact that students' clinical work is a direct reflection of their clinical supervisors' ability to perform the procedure, particularly in the earlier stages of their careers where the clinical supervisor may intervene more frequently.

TABLE 3.

Pooled success rates based on the preoperative pulp/periapical tissues, tooth types and tooth location in the included studies.

Variable No. studies No. roots Pooled success rates
Unweighted success rates (%) a Weighted success rates b
Preoperative pulp diagnosis 3 771
Vital 329 87.1 87.8
Necrotic 442 62.2 65.6
Preoperative periapical lesion 3 771
Absent 477 87.1 86.8
Present 294 55.8 56.3
Tooth type 3 771
Anterior 202 82.2 82.2
Pre‐molar 216 79.4 79.4
Molar 351 68.7 68.7
Arch 3 771
Maxillary 436 76.8 76.8
Mandibular 335 72.1 73.1
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a

Unweighted pooled success rates were calculated following the method outlined by Hepworth and Friedman (1997).

b

Weighted pooled success rates were derived through a random‐effects meta‐analysis.

Limitations of the methodology

From the results of this review, it is evident that while inclusion criteria were met by all selected studies, it was difficult to compare all aspects due to variability in treatment protocols, different methods of evaluating success criteria and the duration of follow‐up. As such, statistical analyses were hampered due to the heterogeneity. Further, other sources of uncertainty, introduced by funding sources and small study bias, cannot be excluded. However, they do not appear likely to change the presented findings.

On the contrary, meta‐analysis was possible for two populations of teeth over three studies (Azim et al., 2016; Polyzos et al., 2018a, 2018b) as those studies further subdivided the teeth into individual roots, which allowed for determination of success rates based on various clinical parameters. The results are derived from a smaller sample size, and this may diminish the validity of the results.

Moreover, the pooled success rates were determined on a per root basis rather than per tooth. Although it is understandable that each root could be considered to have its own root canal system and the impact of multiple host and treatment variables can be assigned to the root as a unit of measurement (Azim et al., 2016), this form of determination may be less useful in understanding the treatment outcome for the patient, who would consider the entire tooth as a success or failure.

Future directions

From an educational perspective, certain questions remained unanswered, such as:

  • Will innovative approaches such as 3D printed models, mobile apps or teaching methodologies improve clinical outcomes?

  • How many treatments do students perform prior to graduation, and is this sufficient for demonstration of competence and self‐efficacy?

  • What is the impact of the type of supervisor (general dentist, post‐graduate endodontic resident or endodontist?), and what is the ideal supervisor‐to‐student ratio?

  • What kind of infrastructure, including magnification, do undergraduate dental students use, and is any of this associated with clinical outcomes?

The quantity of treatments is an important metric to understand for educators. One study reported that on average, each final‐year student treated at least two molars, two pre‐molars and two anterior teeth (De Quadros et al., 2005). A survey study from the Czech Republic on student perception of undergraduate endodontic education identified that insufficient exposure to endodontic practice on patients was identified as a deficiency, and only 48.3% of students that responded to the survey felt confident treating molars (Kapitán et al., 2020). It is expected that students should have performed a certain amount of nonsurgical root canal treatment prior to graduation to meet a minimum competency (De Moor et al., 2013; Sadr et al., 2021), but at the same time, it is unclear how many repetitions of treatment a student should complete prior to graduation. Understanding this metric is important when students become qualified clinicians upon graduation and impacts the quality of treatment when they are in the workforce. As mentioned before, the notion of self‐efficacy is dependent on the demonstration of competence (Baaij et al., 2024).

The type of supervisor may or may not have an impact on students' performance in endodontic treatment. A recent survey study from New Zealand highlighted that students felt more confident and less anxious when supervised by clinicians experienced in endodontics (Friedlander et al., 2023). Although this does not indicate that only endodontists are qualified to supervise undergraduate students, skilled supervisors with expertise in endodontics are likely required to ensure optimal endodontic education.

Supervisor‐to‐student ratio has not been reported in any of the clinical studies examined. These metrics are seldom reported in education‐focused dental studies. Survey studies from Saudi Arabia reported that supervision ratio could range from 1:2 to 1:8 (Algahtani et al., 2023; Bhasker & Alshwaimi, 2015). Conceivably, a lower supervisor‐student ratio would allow for an individualized teaching experience and more time for detailed feedback on clinical work (Algahtani et al., 2023).

Finally, there is currently no insight from the extracted studies on the specific impact of modern dental technology that may enhance students' experience and treatment outcomes. For example, the use of magnification such as dental loupes and dedicated dental headlights may have better treatment outcomes. Studies have shown that dental operating microscopes have improved outcomes in detecting the second mesio‐buccal canal in upper molars (Khalighinejad et al., 2017) and improved overall treatment outcome (Monea et al., 2015). However, it is not disclosed whether undergraduate students have access to or routinely use dental microscopes, or whether the use of loupes would show any impact on treatment outcomes. Further, if loupes do indeed improve treatment outcome, the specific magnification where endodontic treatment is improved is currently not known.

Lastly, innovative teaching methodologies for pre‐clinical activities such as the flipped classroom (Zhou et al., 2022) or small group discussion formats (Arias et al., 2016) will translate into improved clinical performance.

CONCLUSION

The outcomes of nonsurgical root canal treatment performed by undergraduate students are not well understood. Of the 11 available studies for data extraction, limited information could be analysed due to the heterogeneity of the studies. Three studies were eligible for meta‐analysis and showed outcomes in the undergraduate student clinic were similarly dependent on the preoperative pulpal and periapical status as has been reported in general and specialist practice. While the question of treatment numbers has received attention in the past, further exploration into outcomes in the undergraduate student clinic, including the effects of technical and teaching innovations, is critical for shaping endodontic education.

AUTHOR CONTRIBUTIONS

Philip Chien: Data Curation, Formal Analysis, Methodology, Writing—Original Draft Preparation. Sepanta Hosseinpour: Data Curation, Formal Analysis, Visualization, Writing—Original Draft Preparation (supporting). Ove Peters: Conceptualization, Project Administration, Supervision, Writing—Review and Editing. Christine Peters: Conceptualization, Supervision, Writing—Review and Editing.

FUNDING INFORMATION

The authors received no financial support for the research, authorship and/or publication of this article.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no competing interests.

Supporting information

Table S1.

IEJ-59-929-s001.docx (28.4KB, docx)

ACKNOWLEDGEMENTS

Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australian University Librarians.

DATA AVAILABILITY STATEMENT

All meta‐analytic data and codebooks are available from the authors upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1.

IEJ-59-929-s001.docx (28.4KB, docx)

Data Availability Statement

All meta‐analytic data and codebooks are available from the authors upon reasonable request.

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