Effectiveness of Flipped Learning Compared to Conventional Instruction in Teaching Tooth Extraction to Dental Students

ABSTRACT

Objectives

This study aimed to compare the effectiveness of conventional theoretical instruction and flipped learning supported by demonstrative videos in teaching tooth extraction to dental students.

Methods

A prospective, comparative study was conducted during the 2024–2025 academic year with 112 fourth‐year dental students who had no prior experience in tooth extraction. Students were randomized into a flipped learning group (n = 62) and a control group (n = 50). The flipped group received video‐based procedural education, while the control group received conventional lectures. Following their first clinical extraction, all students completed a seven‐item questionnaire assessing unaided performance, anxiety, preparedness, and perceived competence. Statistical analyses included Chi‐square and Mann–Whitney U tests, with effect sizes reported as rank biserial correlation (r).

Results

A significantly greater proportion of students in the flipped group performed the extraction without assistance compared to the control group (58.1% vs. 36.0%, p = 0.0468). The flipped group also reported lower procedural anxiety (p = 0.0468, r = 0.21) and greater perceived sufficiency of instrument training (p = 0.0224, r = 0.24). However, no significant group differences were observed in perceived usefulness of instruction, theoretical preparation, or self‐rated instrument competence.

Conclusions

Flipped learning improved students’ procedural independence and reduced anxiety during their first clinical extraction. While beneficial for technical and emotional preparedness, flipped instruction alone may not sufficiently enhance students’ self‐perceived competence or theoretical readiness. These findings support incorporating flipped learning into dental curricula while highlighting the need for complementary strategies to foster clinical confidence

1. Introduction

Dental education requires students to integrate theoretical knowledge with psychomotor skills [1]. Among these, tooth extraction is a fundamental clinical procedure that demands not only technical precision but also cognitive readiness and emotional resilience. Developing such competencies is particularly challenging for undergraduate students, as it involves the coordination of cognitive, sensory, and neuromuscular functions, often under stressful clinical conditions [2].

Traditional preclinical training methods rely on laboratory‐based instruction and didactic lectures. However, limited session duration, suboptimal visibility during demonstrations, and inconsistencies in instructor feedback can hinder students’ preparedness for real patient encounters [3]. These challenges have been reported to compromise learning efficiency, reduce students’ confidence, and contribute to variation in skill acquisition [4]. Consequently, there is increasing interest in alternative instructional models supporting technical development and clinical readiness through standardized, repeatable, and visually enriched learning environments.

Flipped learning can be defined as a pedagogical approach in which core instructional content is delivered outside of class, allowing classroom time to be dedicated to interactive discussions, problem‐solving, and skill application [5]. In this model, lessons are delivered through videos prepared by the instructor, allowing face‐to‐face time between the instructor and students to be used more meaningfully, creating a richer learning environment. Procedural videos ensure standardized and consistent learning experiences for all students [6]. This approach has been increasingly adopted in medical and dental education to address curriculum overload and enhance student engagement [7]. Previous studies have demonstrated that flipped learning enhances student performance in various clinical domains, including local anesthesia [8], implant dentistry [9], and restorative procedures [10], while also improving learner satisfaction and confidence. However, the flipped classroom model also has certain limitations. It requires substantial preparation time and technological resources, and not all students may engage effectively with pre‐class materials, which can lead to variability in learning outcomes [11].

The present study aims to evaluate the effectiveness of flipped learning in teaching tooth extraction to dental students. By comparing a conventional lecture‐based instructional model with a flipped approach supported by demonstrative videos, the study investigates whether video‐enhanced preparation improves procedural competence, reduces anxiety, and increases students’ perceived readiness. Given the growing emphasis on competency‐based and active learning frameworks in dental education, the findings of this study may inform curriculum development and instructional design aimed at enhancing early clinical training. To the best of our knowledge, this is the first study to apply a flipped learning model specifically to the teaching of tooth extraction. While flipped approaches have been reported in other areas of dental education, such as local anesthesia, implant dentistry, and restorative procedures, there remains a gap in the literature regarding their application to basic surgical skills like extraction. This study therefore addresses an important unmet need in early clinical training.

2. Methods

2.1. Study Design

This prospective, comparative study was designed to evaluate the effectiveness of flipped learning versus traditional theoretical instruction in teaching tooth extraction. The study followed the principles of the Declaration of Helsinki and received approval from the Clinical Research Ethics Committee of (blinded) University (Approval No: 2024/494). Written informed consent was obtained from all participants prior to their enrollment.

2.2. Participants

A total of 112 fourth‐year dental students (in a five‐year program) from a single dental school participated in this study. All students had no prior clinical experience with tooth extraction. Participants were randomly assigned to one of two groups using a computer‐generated random number sequence prior to the start of their clinical internship. As a result, the flipped learning group included 62 students, while the conventional instruction group included 50 students. This minor imbalance resulted from the randomization procedure. As all between‐group comparisons were conducted using Fisher's Exact test and Mann–Whitney U test, which are robust to unequal group sizes, this imbalance did not compromise the validity of the statistical analyses. Randomization was not stratified by factors such as gender or academic background.

Both groups attended the standard theoretical lectures included in the curriculum. Students in the flipped learning group (n = 62) participated in a supervised session three days before their clinical extraction, during which they watched a 25‐min instructional video and were allowed to ask questions and request clarification from the instructor, ensuring an interactive learning environment consistent with the flipped learning approach. The videos, prepared by expert faculty members from the Department of Oral and Maxillofacial Surgery, systematically demonstrated key steps of the tooth extraction procedure, including local anesthesia administration, the use of elevators and forceps, and post‐extraction care. (Figure 1) To prevent unauthorized sharing of the instructional material with the control group, students in the flipped group viewed the videos under supervision in the presence of a surgical assistant. (Figure 2) Viewing was scheduled in small groups, and students were not provided access to the videos outside the designated session. The role of the instructor was limited to ensuring equal access to the video and answering questions for clarification. The control group (n = 50) received conventional theoretical instruction through lectures and slides without video supplementation.

FIGURE 1.

Application of forceps and luxation during the extraction of a decayed molar tooth.

FIGURE 2.

Students in the flipped learning group viewing a procedural video on tooth extraction.

2.3. Clinical Procedure

All students performed their first tooth extraction under supervision as part of their internship training. Instructor intervened only when it was necessary to ensure patient safety. To minimize bias, supervising clinicians were blinded to students’ group assignments. The extent of assistance required during the extraction was recorded by the faculty immediately following the procedure. In this study, “assistance” was defined narrowly and recorded only when the instructor played an active role in a major part of the procedure or had to complete the extraction on behalf of the student. No formal rubric was applied.

2.4. Questionnaire Design and Data Collection

Immediately following the extraction, students completed a structured questionnaire consisting of seven items evaluating their procedural experience, emotional preparedness, and perceived competence. The items were:

1. Were you part of the group that watched instructional videos before the internship? (Yes/No)

2. Were you able to perform your first extraction without assistance? (Yes/No)

3. I felt anxious before and during the extraction procedure.

4. The instructional video provided helpful preparation for the procedure.

5. I believe the theoretical training was sufficient for performing tooth extraction.

6. I received adequate training on the use of elevators and forceps.

7. I feel confident in using elevators and forceps during the extraction.

Items 3 through 7 were rated using a five‐point Likert scale (1 = strongly disagree to 5 = strongly agree). The questionnaire was constructed based on conceptual domains from established instruments, including the State‐Trait Anxiety Inventory (STAI) [12] for emotional preparedness, instructional satisfaction frameworks for perceived training adequacy, and the General Self‐Efficacy Scale (GSE) [13] for procedural confidence. Although not formally validated due to study constraints, the questionnaire was theoretically grounded in these widely used measurement tools.

2.5. Statistical Analysis

All statistical analyses were performed using SPSS version 23 software (IBM Corp., Chicago, Ill., USA). Descriptive statistics were calculated for all variables. Between‐group comparisons for binary outcomes (e.g., unaided extraction) were assessed using the Chi‐square test or Fisher's exact test, as appropriate. Likert‐type responses were analyzed using the non‐parametric Mann–Whitney U test due to the ordinal nature of the data. To estimate the magnitude of group differences, rank biserial correlation coefficients (r) were calculated as effect sizes. A two‐tailed p‐value < 0.05 was considered statistically significant.

3. Results

A total of 112 students participated in the study—62 in the flipped learning group and 50 in the conventional instruction group. No participants were excluded or lost to follow‐up.

3.1. Procedural Independence

A significantly higher proportion of students in the flipped learning group reported completing their first tooth extraction without assistance compared to the control group (58.1% vs. 36.0%). This difference was statistically significant (p = 0.0468, Fisher's exact test), and the calculated odds ratio was 2.46, indicating that students in the flipped group were 2.46 times more likely to perform the procedure unaided (Table 1).

TABLE 1.

Effect of flipped learning on the success of performing the first tooth extraction without assistance.

	n (Total)	Extraction success (n, %)	Odds ratio [95% CI]	p‐value
Flipped Learning Group	62	36 (58.1%)	2.46 [1.14–5.30]	0.0468 *
Control Group	50	18 (36.0%)

Note: p‐value calculated using Fisher's Exact Test (two‐tailed).

Abbreviations: %, percentage of group total; CI, confidence interval; n, number of participants.

^* p‐value < 0.05 was considered statistically significant.

3.2. Anxiety

Students in the flipped group reported significantly lower anxiety levels prior to and during the procedure (p = 0.0468, r = 0.21).

3.3. Perceived Training Adequacy

Students in the flipped group rated their training in the use of elevators and forceps as more adequate than those in the control group (p = 0.0224, r = 0.24). However, no statistically significant difference was observed between groups in their ratings of theoretical preparation (p = 0.2409) or the perceived usefulness of instruction (p = 0.1826).

3.4. Self‐Perceived Competence

There was no significant group difference in students’ confidence in using elevators and forceps during extraction (p = 0.0823).

Descriptive statistics and test results for all questionnaire items are presented in Table 2. A visual summary of group differences in Likert‐scale responses is shown in Figure 2.

TABLE 2.

Effect of flipped learning on self‐reported outcomes.

Outcome	Flipped median (Min–Max)	Control median (Min–Max)	p‐value	Effect size (r)
Anxiety during extraction	3 (1–5)	4 (1–5)	0.0468 *	0.21
Usefulness of instruction	5 (3–5)	4 (3–5)	0.1094	−0.16
Theoretical preparation adequacy	4 (1–5)	3 (1–5)	0.1380	−0.16
Instrument training sufficiency	4 (2–5)	3 (1–5)	0.0224 *	0.24
Competence with instruments	3 (1–5)	3 (2–5)	0.7596	−0.03

Note: r = effect size calculated from Mann–Whitney U test.

^*A p‐value < 0.05 was considered statistically significant. Median values are presented with minimum and maximum in brackets.

4. Discussion

This study demonstrated that implementing a flipped learning model supported by demonstrative videos significantly improved students’ ability to perform their first tooth extraction without assistance and reduced their anxiety during the procedure. Specifically, students in the flipped group were more than twice as likely to complete the procedure unaided compared to those receiving conventional instruction. These findings suggest that video‐based preparation not only enhances technical readiness but also contributes to emotional preparedness in clinical dental education.

The findings emphasize the practical advantages of flipped learning in clinical skill acquisition. By allowing students to access procedural content, such as local anesthesia administration, instrument handling, and step‐by‐step extractions, before clinical exposure, the flipped model may have facilitated better psychomotor readiness. This aligns with previous research showing that flipped learning enhances performance in hands‐on procedures. For example, Wu et al. [9] demonstrated improved implant placement accuracy in a flipped classroom model, while Chen et al. [8] reported higher competence in local anesthesia techniques among students trained with video materials. A broader meta‐analysis by Hew and Lo [14] similarly highlighted modest yet consistent gains in learning outcomes across health professions using flipped approaches.

Despite improvements in both clinical performance and reduced anxiety, students in the flipped group did not report greater self‐perceived competence or theoretical preparedness. This suggests a partial disconnect between observed behavioral gains and internalized confidence, highlighting that technical preparation alone may not fully translate into self‐efficacy. Similar patterns have been described in previous studies; for instance, while Saheb et al. [15] reported increased confidence without measurable skill improvement, our findings represent the reverse, objective improvement accompanied by limited change in self‐assessment. This divergence is also supported by Atik et al., who found that while live‐video demonstrations improved dental students’ satisfaction and perceived preparedness in orthodontic wire‐bending, no significant enhancement in objective performance was observed [16]. These results indicate that flipped learning, although effective in cognitive and technical domains, may benefit from being paired with reflective or mentorship‐based interventions to strengthen students’ clinical self‐confidence.

The high‐stakes nature of performing a first extraction is widely recognized as a source of anxiety among dental students. However, in this study, students in the flipped group reported significantly lower levels of anxiety compared to those receiving traditional instruction. This suggests that preparatory video‐based instruction may help reduce emotional distress in early clinical experiences. Nevertheless, overall psychological readiness likely evolves through repeated exposure and accumulated clinical practice, as emphasized by Tokuc et al. [17], who noted that surgical procedures, particularly extractions, are inherently anxiety‐inducing regardless of preparation strategy.

Importantly, the flipped classroom appears to offer a viable solution to the longstanding gap between theoretical learning and practical execution in dental curricula. By providing structured, visual exposure prior to clinical procedures, students develop a foundational mental model, which facilitates more efficient and independent application under supervision. In line with recent literature, flipped learning environments have been shown to improve student engagement and allow classroom time to be repurposed for interactive, skill‐based practice [18, 19]. However, consistent with our findings, this instructional model alone may not be sufficient to enhance all dimensions of clinical confidence. Additional strategies, such as guided debriefings, formative peer feedback, and longitudinal mentorship, may be required to reinforce students’ self‐efficacy and emotional readiness.

This study has several limitations that should be considered when interpreting the findings. First, although the questionnaire was developed based on validated constructs (e.g., STAI, GSE), it was not formally validated as a composite tool. Second, the emotional and psychological impacts of flipped learning may evolve over time, but this study only assessed immediate outcomes following the first clinical experience. Third, while faculty instructors were blinded to group allocation, students were aware of their instructional group, which may have introduced expectancy bias. In addition, randomization was not stratified by variables such as gender or prior academic background, and although random allocation is expected to distribute these factors evenly, potential imbalances cannot be excluded. Despite these limitations, the study provides preliminary evidence supporting the integration of flipped learning into undergraduate oral surgery curricula. Future studies should investigate its impact on long‐term clinical outcomes, student satisfaction, and performance in more complex surgical tasks. Incorporating structured video debriefings, peer discussion, and feedback mechanisms may further enhance its effectiveness.

5. Conclusion

In conclusion, flipped learning demonstrates meaningful benefits in preparing dental students for their first clinical experiences, particularly by enhancing procedural independence and reducing anxiety. However, the lack of significant improvement in self‐perceived competence and theoretical readiness underscores the limitations of technical training alone. Educational strategies that combine flipped instruction with reflective, emotional, and feedback‐oriented components may be more effective in promoting comprehensive clinical readiness. These findings support the integration of active learning models into dental curricula while emphasizing the importance of addressing both cognitive and affective domains in clinical education.

Author Contributions

Concept—EAS, EE, EB, GD, OK, AY; Design—EAS, EE, EB; Supervision—EAS, EB; Resources—EAS, EE, EB, GD, OK, AY; Materials—EAS, EE, GD, OK, AY; Data Collection and/or Processing—EE, GD, OK, AY; Analysis and/or Interpretation—EAS; Literature Search—EAS, EE; Writing Manuscript—EAS; Critical Review—EAS, EE, EB, GD, OK, AY

Funding

The authors received no specific funding for this work.

Ethics Statement

The study followed the principles of the Declaration of Helsinki and received approval from the Clinical Research Ethics Committee of Ondokuz Mayıs University (Approval No: 2024/494). Written informed consent was obtained from all participants prior to their enrollment.

Consent

Written informed consent was obtained from all participants prior to their enrollment.

Conflicts of Interest

The authors declare no conflicts of interest.