Keywords
dental magnification - endodontics - root canal therapy - dental students - teaching
Introduction
The use of magnification devices has become essential in endodontic treatment.[1] Additionally, it is thought that integrating magnification devices into undergraduate
education is necessary to increase students' confidence and competence in performing
root canal treatments.[2]
Magnification tools like dental loupes and microscopes have grown in importance in
dentistry over the past few decades. A safe and efficient method of enhancing the
results of challenging endodontic procedures is the application of magnification in
conjunction with lighting.[3]
[4]
Although some studies suggest that the type of magnification device used may have
minimal effects on treatment outcomes,[5] others highlight the benefits of magnification in improving the accuracy and quality
of dental work.[6]
Magnification is currently seen as a crucial element of both general dentistry and
expert endodontic practice (American Association of Endodontists, 2012). The British
Endodontic Society Teachers of Endodontology Group provided new data on the influence
of dental operating microscopes (DOMs) on endodontic treatments in providing enhanced
illumination and magnification. However, integrating DOMs into general dentistry practice
and undergraduate endodontic education has practical, financial, and ergonomic concerns.[7]
As a result, using dental loupes with illumination is advised in this position statement
as a minimal requirement for nonsurgical endodontics performed at the undergraduate
level.[7] Dental loupes have been demonstrated to be beneficial in assisting in the identification
of root canal anatomy, detecting cavities, and promoting conservative cavity preparation.[3]
[7]
[8]
[9]
Despite the fact that endodontic teaching leaders use magnification in their own clinical
practice, the study found that this did not translate into the design and delivery
of training and the expectation that undergraduate students will use magnification.[10] This is illogical, inconsistent, and not in line with best clinical practice for
tutors to use magnification in their own practice and not be included in undergraduate
training.[7]
Endodontic therapy is a fundamental component of dental education, requiring students
to develop high levels of precision and technical proficiency. However, undergraduate
dental students often face significant challenges in mastering these skills, particularly
in tasks such as locating canal orifices, negotiating curved canals, and achieving
optimal obturation. While magnification tools such as dental loupes and operating
microscopes have been widely adopted in clinical practice, their impact on the learning
and performance of undergraduate students remains poorly understood. Existing studies
on this topic are fragmented, with limited synthesis of evidence regarding the effectiveness
of magnification in improving technical performance, skill acquisition, and student
confidence.
The key knowledge gaps include insufficient knowledge of the effects of magnification
on technical performance at various student curriculum levels, insufficient investigation
of the effects of magnification devices on learning curves and the acquisition of
fine motor skills, brief discussion of suggested curriculum design, training timelines,
and institutional obstacles as well as lack of standardized recommendations regarding
the best timings and techniques to use magnification in undergraduate instruction.
This narrative review aims to address this gap by comprehensively examining the existing
literature on the use of magnification in endodontic therapy among undergraduate dental
students, with the goal of evaluating the effect of magnification on student technical
performance, learning and skill acquisition, student confidence and educational implications,
informing evidence-based teaching practices, and identifying areas for future research.
This review tests the null hypothesis that magnification use does not significantly
improve technical performance, learning curves, or confidence compared with conventional
methods. By synthesizing data (2016–2024), we aim to identify best practices for curricular
integration, propose policy solutions for resource-limited settings, and prioritize
future research on long-term skill retention.
Methods
Search Strategy
A comprehensive search was conducted to identify relevant studies addressing the impact
of magnification on the performance of undergraduate dental students performing endodontic
therapy. The following steps were taken to ensure a thorough and reproducible search
process:
-
Databases searched: PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar
were searched to identify peer-reviewed articles, conference proceedings, and theses/dissertations.
-
MeSH keywords and search terms: the following MeSH keywords were used to refine the
search: (Magnification OR loupe OR “dental operating microscope”) AND (endodontics
OR “root canal therapy” OR “root canal therapies” OR endodontology) AND (student OR
undergraduate OR “dental student” OR teach*). Truncation (*) and phrase searching
(“ ”) were employed to capture variations in terminology.
-
Timeframe: studies published within the past 9 years (from 2016 to 2024) were included
to ensure relevance to current practices and technologies. This window captures the
most recent evidence on incorporation of magnification in undergraduate endodontic
teaching, ensuring the reflection of current practices. Pre-2016 studies were excluded
to maintain focus on contemporary curricula.
-
Language: only studies published in English were included. Studies in other languages
were excluded unless translation was feasible and relevant.
Focus question: in accordance with the Population, Intervention, Comparison, and Outcomes framework,
the following research question was formulated: population: undergraduate dental students.
Intervention: use of magnification tools during endodontic therapy. Comparison: undergraduate
dental students performing endodontic therapy without magnification aids. Outcomes:
technical performance in endodontic therapy, learning and skill acquisition, confidence
levels, and educational implications.
Eligibility Criteria
Inclusion criteria: studies were included based on the following criteria:
-
Population: studies involving undergraduate dental students performing endodontic
therapy; studies focusing on the use of magnification tools (e.g., dental loupes,
microscopes) in endodontic procedures.
-
Intervention/exposure: studies evaluating the use of magnification devices during
endodontic therapy; studies comparing performance outcomes with and without magnification.
-
Outcomes: studies reporting measurable performance outcomes, such as accuracy, precision,
success rates, or efficiency in endodontic procedures; studies assessing learning
curves, skill acquisition, or confidence levels related to magnification use; studies
assessing inclusion of magnification in dental curricula.
-
Study design: randomized controlled studies, cross-sectional surveys, observational
studies, or comparative studies; peer-reviewed journal articles or theses/dissertations.
-
Language: studies published in English.
-
Timeframe: studies published from 2016 to 2024.
Exclusion criteria: studies were excluded based on the following criteria:
-
Population: studies involving postgraduate students or experienced clinicians; studies
focusing on nonendodontic procedures (e.g., restorative dentistry, oral surgery).
-
Intervention/exposure: studies that did not specifically address the use of magnification
tools in endodontic therapy.
-
Outcomes: studies that did not report measurable performance outcomes related to endodontic
therapy; studies with unclear or irrelevant outcome measures.
-
Study design: case reports, editorials, opinion pieces, or narrative reviews without
original data; studies with insufficient methodological rigor (e.g., lack of control
groups, small sample sizes without justification).
-
Language: studies published in languages other than English.
-
Timeframe: studies published prior to 2016.
Study Selection
Studies were selected according to the PRISMA flow diagram ([Fig. 1]). Initially, 237 records were identified through database searching (PubMed, Scopus,
Web of Science, Cochrane Library, and Google Scholar). After removing 25 duplicates,
13 ineligible studies by automation criteria and 21 for other reasons, 178 titles/abstracts
were screened. Of these, 128 full-text articles were assessed for eligibility, with
50 studies ultimately included. Excluded studies (n = [38]) were documented with reasons within the exclusion criteria.
Fig. 1 Prisma flow diagram.
Data Extraction and Analysis
-
Screening process: titles and abstracts of identified studies were screened for relevance based on
the inclusion and exclusion criteria. Full-text articles were reviewed for eligibility,
and data were extracted using a standardized form with exclusions documented (e.g.,
“wrong population” or “no magnification focus”). Discrepancies were resolved by re-evaluating
the source material against eligibility criteria.
-
Data extraction: the following data were extracted from included studies: study characteristics (author,
year, country, study design); population details (sample size, demographic information);
intervention details (type of magnification tool); comparison groups; outcome measures
(performance metrics, learning curves, confidence levels); and key findings and conclusions.
A standardized, pilot-tested extraction form was used to collect:
-
Study characteristics: author, year, country, design, funding sources.
-
Population: undergraduate dental student level (e.g., preclinical/clinical), institution
type.
-
Intervention: magnification tool (e.g., loupes, microscopes), duration of use, training
protocol.
-
Comparison: unaided vision.
-
Outcomes: objective metrics (performance metrics, learning curves, confidence levels)
and subjective measures (e.g., student surveys).
-
Key findings: statistical significance, effect sizes (if reported), and author conclusions.
The form was piloted on three randomly selected studies and refined for clarity. Extracted
data were cross-verified against original articles to ensure accuracy.
-
Quality assessment: the methodological quality of included studies was assessed using appropriate tools,
such as the Cochrane Risk of Bias Tool for randomized controlled trials or the Newcastle–Ottawa
Scale for observational studies.
-
Synthesis: a narrative synthesis was conducted to summarize the findings. Studies were grouped
by themes, such as technical performance, learning and skill acquisition, student
confidence, and educational implications.
Limitations
-
Language bias: only English-language studies were included, which may have excluded
relevant studies published in other languages.
-
Timeframe: restricting the search to the past 10 years may have excluded older but
relevant studies.
-
Heterogeneity: variability in study designs, outcome measures, and magnification tools
may limit the comparability of findings.
Critical Appraisal of Included Studies
To evaluate the methodological rigor of the selected studies, a qualitative assessment
was conducted focusing on sample size, outcome measures, and potential biases. Given
the heterogeneity in experimental approaches (e.g., varying magnification devices,
skill assessment methods), a narrative synthesis was deemed more appropriate than
a meta-analysis. The following limitations were noted across studies:
Small sample sizes or unavailability of sample sizes in some trials (e.g., Al Agha
[22] sample size 20 students; Wajngarten et al [21], n = 24; Alobaid et al [34] studies 15 out of 21 dental schools in Saudi Arabia due
to lack of response from remaining schools; reducing statistical power ([Table 1]).
Table 1
Critical appraisal of included studies
|
Study
|
Design
|
Sample size
|
Key strengths
|
Key weaknesses
|
|
Alhazzazi et al (2016)[6]
|
Cross-sectional survey study
|
651
|
Identifies practical barriers, regional baseline data (establishes Saudi Arabian context
for comparison with global studies)
|
Single-institution bias, temporal concerns published 2017 (may not reflect current
curricula), nonvalidated instrument (survey tool not psychometrically tested)
|
|
Al Raisi et al (2019)[21]
|
Cross-sectional survey study
|
16 UK dental schools
|
Comprehensive national data (94% response rate from all UK dental schools), curriculum-specific
insights
|
Faculty perspective only (lack of student perspective), limited clinical correlation
(reports what is taught but not effectiveness)
|
|
Al Agha (2020)[17]
|
Randomized controlled trial
|
20
|
RCT, objective measurement
|
Small sample size, limited sample diversity (one institution)
|
|
Brown et al (2020)[10]
|
Cross-sectional survey study
|
15/18 UK and Ireland course leads in UK and Ireland
|
Magnification-specific focus, comparative value (expands on Al Raisi et al [2019]
with Ireland-inclusive data)
|
Faculty-only perspective (lack of student perspective), limited contextual data (does
not evaluate magnification's effect on procedural quality)
|
|
Braga et al (2021)[15]
|
Randomized controlled trial
|
93
|
RCT, blinded assessment, standardized simulation, objective outcome measures, focused
on undergraduates
|
Simulated nonclinical setting, short-term evaluation, potential Hawthorne effect,
limited sample diversity (one institution), loupe variables uncontrolled (different
magnifications)
|
|
Wajngarten et al (2021)[18]
|
RCT (crossover)
|
92
|
High-level evidence (crossover RCT), blinding of assessors, statistical rigor
|
Simulated tasks (lack the complexity of actual clinical procedures), single-institution
bias, loupe familiarity variability
|
|
Wajngarten et al (2021)[16]
|
Qualitative study
|
24
|
Educational insights
|
Small sample size, single-institution bias
|
|
da Costa Ferreira et al (2021)[23]
|
Cross-sectional survey study
|
19/54 dental schools
|
Technology-specific data (quantifies loupe adoption rates, identifies barriers)
|
Superficial technology analysis (groups all magnification devices together, does not
differentiate loupes vs. microscopes)
|
|
Segura-Egea et al (2021)[22]
|
Cross-sectional survey study
|
22/23 Spanish dental schools
|
Detailed curriculum analysis, comparative value (allows direct comparison with UK
studies [Brown et al 2020, Al Raisi et al 2019])
|
Faculty perspective only (lack of student perspective), limited clinical correlation
(reports what is taught but not effective)
|
|
Alobaid et al (2022)[24]
|
Cross-sectional survey study
|
15/21 Saudi Arabia dental colleges
|
Detailed curriculum assessment, comparative value
Allows comparison with similar studies (e.g., Brown et al, 2020—UK, Segura-Egea et
al, 2021—Spain)
|
Self-reporting bias (relies on subjective perceptions rather than objective skill
assessments), limited clinical correlation (reports availability of magnification
but not effectiveness in training)
|
|
Algahtani et al (2023)[25]
|
Cross-sectional survey study
|
25/26 Saudi Arabia dental schools
|
Robust sample size and diversity (covers multiple institutions across Saudi Arabia,
reducing single-center bias)
|
Nonrandom sampling (potential selection bias (respondents may be more tech-savvy or
motivated, does not account for nonrespondents' experiences)
|
|
Alsughier et al (2024)[20]
|
Cross-sectional survey study
|
368
|
Comprehensive population sampling, regional relevance,
|
Self-report bias (subjective perceptions), lack of objective measures (does not correlate
perceptions with clinical performance data)
|
Abbreviation: RCT, randomized controlled trial.
Risk of Bias Assessment
The methodological quality of included studies was assessed using:
-
ROB-2 for randomized trials.[15]
-
Newcastle–Ottawa Scale for observational studies.
-
JBI Checklist for qualitative studies ([Table 2]).[16]
Table 2
Risk of bias/quality Assessment
|
Study
|
Design
|
Tool
|
Key bias domains
|
Overall bias
|
|
Alhazzazi et al (2016)[6]
|
Cross-sectional survey
|
NOS
|
 Self-report bias;  Response rate;  Sample size
|
High risk
|
|
Al Raisi et al (2019)[21]
|
Cross-sectional survey
|
NOS
|
100% response rate; Faculty-only; Clarity
|
Unclear
|
|
Brown et al (2020)[10]
|
Cross-sectional survey
|
NOS
|
100% response rate; Faculty-only bias; Clear objectives
|
Unclear
|
|
Al Agha (2020)[17]
|
Randomized controlled trial
|
NOS
|
No control group; Follow-up; Outcome assessment
|
High risk
|
|
Braga et al (2021)[15]
|
Randomized controlled trial
|
ROB-2
|
Randomization; Blinding (performance); Selective reporting
|
Some concerns
|
|
Wajngarten et al (2021)[18]
|
Randomized controlled trial
|
ROB-2
|
Randomization; Blinding; Selective reporting
|
Low risk
|
|
Wajngarten et al (2021)[16]
|
Qualitative
|
JBI
|
Participant alignment; Researcher bias; Ethical rigor
|
Low risk
|
|
Segura-Egea et al (2021)[22]
|
Cross-sectional survey
|
NOS
|
Pre-COVID data; Multi-center; No outcomes
|
High risk
|
|
da Costa Ferreira et al (2021)[23]
|
Cross-sectional survey
|
NOS
|
Single-state; Convenience sampling; Objective measures
|
Unclear
|
|
Alobaid et al (2022)[24]
|
Cross-sectional survey
|
NOS
|
Dual-perspective; Nonrandom; No skill assessment
|
High risk
|
|
Algahtani et al (2023)[25]
|
Cross-sectional survey
|
NOS
|
Large sample; Recall bias; No longitudinal data
|
Unclear
|
|
Alsughier et al (2024)[20]
|
Cross-sectional survey
|
NOS
|
Nonvalidated tool; Sampling; Statistical analysis
|
Unclear
|
Note: = Low risk,
= Some concerns/unclear,
= High risk.
Results
A total of 12 studies were included in this review. The studies involved undergraduate
dental students performing endodontic therapy with and without magnification tools.
Technical Performance
Magnification is widely regarded as a significant advancement in dentistry, with many
dental schools encouraging its use during training.[6]
[11]
[12]
[13]
[14]
Braga et al[15] compared students using 2.5× magnification loupes with those using unaided vision.
The students were evaluated on the positioning of the canal, internal form taper,
internal outline, access opening, and access cavity size and shape. According to Braga
et al, students who used magnifying loupes had a noticeably greater pass percentage
than those who did not.
Wajngarten et al[16] evaluated the opinions of dental students at Stony Brook University regarding the
use of 2.5× magnification. It was revealed that students had adjusted well to the
loupes.
Al Agha[17] demonstrated that the amount of tooth tissue removed during an endodontic access
cavity procedure by inexperienced undergraduate students appears to be unaffected
by magnification (loupes).
Findings related to technical performance are summarized in [Table 3].
Table 3
Findings related to technical performance
|
Study
|
Target group
|
Methodology
|
Findings
|
|
Al Agha (2020)[17]
|
Undergraduate dental students, Liverpool, UK
|
Evaluation of the amount of tooth tissue removal following endodontic access preparation
using analytical balance, an optical scanner, and cone beam computed tomography (CBCT)
|
The group using magnifying loupes and the unaided vision group did not significantly
differ in terms of access cavity size.
|
|
Braga et al (2021)[15]
|
Third-year dental students
|
Evaluated the impact of the use of 2.5× dental loupes for third-year dental students
in simulated endodontics assessments compared with those using no magnification.
|
The pass rate was higher for the students who used loupes in endodontic group (92.3%
vs. 75.9%, p = 0.038)
|
|
Wajngarten et al (2021)[18]
|
Second-year dental students, StonyBrook School of Dental Medicine, United States
|
Semi-structured interviews exploring the students' perspectives of wearing dental
loupes during their preclinical activities.
|
Most students stated that magnification enhanced the quality of their preclinical
activities.
|
Learning and Skill Acquisition
Wajngarten et al[16] reported that students in Stony Brook School of Dental Medicine, United States adjusted
well to Galilean loupes, though fine motor tasks initially took longer without magnification.
Wajngarten et al[18] assessed the magnification effect on fine motor skills of all undergraduate students
in the fifth and final year of the dentistry program at the School of Dentistry of
São Paulo State University, using the Dental Manual Dexterity Assessment developed
by Neves et al,[19] which showed improved fine motor skills with magnification, despite slower initial
performance.
Findings related to learning and skill acquisition are summarized in [Table 4].
Table 4
Findings related to learning and skill acquisition
|
Study
|
Target group
|
Methodology
|
Findings
|
|
Wajngarten et al (2021)[16]
|
Second-year dental students, Stony Brook School of Dental Medicine, United States
|
Semi-structured interviews exploring the students' perspectives of wearing dental
loupes during their preclinical activities.
|
Students have adjusted well to the loupes.
|
|
Wajngarten et al (2021)[18]
|
Fifth-year undergraduate dental students, Sau Paulo, Brazil.
|
A laboratory-based experimental study. The dependent variables were real motor skills,
perceived motor skills, and time required to complete the fine motor skills test.
The independent variable was the use of a magnification system under four conditions.
For each condition, the Dental Manual Dexterity Assessment was performed.
|
The results show that the magnification systems evaluated positively affected students'
real fine motor skills, regardless of the magnifying devices type used.
|
Student Confidence
Alsughier et al[20] assessed the impact and advantages of using magnification equipment in endodontic
treatment, through a cross-sectional study performed among Saudi Arabian endodontists,
undergraduate and postgraduate students, where a significant percentage of participants
in Saudi Arabia dental schools (30.98%) stated that employing magnification equipment
had multiple benefits (increased quality of clinical work, reduced musculoskeletal
strain, high confidence in clinical procedures, better trust from the patients), demonstrating
a thorough understanding of their benefits. However, a lower percentage (8.70%) indicated
greater confidence in clinical procedures.
Educational Implications
Alhazzazi et al[6] stated that 78.1% of dental students and residents in King Abdulaziz University,
Kingdome of Saudi Arabia did not use magnification during dental procedures. However,
81.8% agreed that dental magnification could enhance the accuracy and quality of their
dental work, and 91.6% thought it would be useful in endodontics. Of the 21.9% that
used magnification, dental loupes were mostly used, 55.9%. In addition, 59.4% of the
participants believed that using dental magnification should be introduced by faculty
beginning in Year 1 of dental school.
Al Raisi et al[21] assessed undergraduate endodontic education in dental schools in the United Kingdom,
concluding that magnification including both loupes and DOM was used during preclinical
and clinical endodontic training in 33% of United Kingdom dental schools. While 27%
of schools utilized loupes for clinical training, only 20% used them for preclinical
training. Twenty percent of them did not use magnification devices.
Brown et al[10] examined the use of magnification in undergraduate endodontic instruction in United
Kingdom and Irish dentistry schools and reported that 53% of course leads in United
Kingdom and Ireland dental schools stated that the official endodontic curriculum
includes magnification, where 87% of respondents said that it should be included in
curricula. In 87% of colleges, it was not expected that undergraduates would use loupes.
Nonetheless, students were urged to utilize magnification during endodontic procedures
in all universities. Fifty percent of respondents said that magnification promotion
was performed in later years. DOMs are offered for preclinical training in 53% of
schools. They are also available chairside in teaching clinics in all schools.
Segura-Egea et al[22] assessed the state of endodontic education at the undergraduate level in Spanish
dental schools and found that no magnification devices were used in 90% of Spanish
dental schools.
da Costa Ferreira et al[23] investigated how much modern endodontic technology was incorporated into undergraduate
dentistry programs in a state in southeast Brazil and reported that 70% of Brazil
dental schools had never included microscopes in their undergraduate curricula.
Alobaid et al[24] assessed the undergraduate endodontic curriculum's delivery and content in Saudi
Arabian dental schools and concluded that 33% of dental schools in Saudi Arabia teach
preclinical students the use of magnifying devices. During clinical years, 53% provide
training in magnification equipment.
On the other hand, Algahtani et al[25] reported that 84% of dentistry schools in Saudi Arbia did not utilize magnification.
Moreover, Alsughier et al[20] stated that 45% of undergraduate, postgraduate students, and endodontists in Saudi
Arabia use a magnifying device (fourth-year students: 21%, fifth-year students: 28%,
and postgraduate programs: 52%). All endodontists surveyed used tools for magnification.
Seventy-four percent of fourth-year students said surgical microscopes were the most
useful. Fifth-year students' preferences were between surgical microscopes (69%) and
loupes with LED lights (28%).
Findings related to educational implications are summarized in [Table 5].
Table 5
Findings related to educational implications
|
Study
|
Target group
|
Methodology
|
Findings
|
|
Alhazzazi et al (2016)[6]
|
Dental students and residents in King Abdulaziz University, Kingdom of Saudi Arabia
|
An e-questionnaire was formulated then sent to dental students and residents (n = 651). The questionnaire included questions that assessed both awareness and attitude
toward using dental magnification.
|
78.1% did not use magnification during dental procedures. However, 81.8% agreed that
dental magnification could enhance the accuracy and quality of their dental work.
91.6% thought it would be useful in endodontics. Of the 21.9% that used magnification,
dental loupes were mostly used, 55.9%. 59.4% of the participants believed that using
dental magnification should be introduced by faculty beginning in Year 1 of dental
school.
|
|
Al Raisi et al (2019)[21]
|
UK dental schools
|
An online survey on undergraduate endodontics education sent via email to the undergraduate
endodontic program leads in the 16 UK dental schools.
|
Magnification including both loupes and dental operating microscope was used during
preclinical and clinical endodontic training in 33% of schools. Twenty per cent of
schools used loupes in preclinical training while 27% employed loupes in clinical
training.
|
|
Brown et al (2020)[10]
|
UK and Ireland dental schools.
|
An electronic questionnaire was distributed to teaching leads in undergraduate endodontics
in all UK and Ireland dental schools.
|
53% of course leads stated that the official endodontic curriculum includes magnification.
87% of respondents said that it should be included in curricula. In 87% of colleges,
it was not expected that undergraduates would use loupes. Nonetheless, students were
urged to utilize magnification during endodontic procedures in all universities. Fifty
percent of respondents said that magnification promotion was performed in later years.
DOMs are offered for preclinical training in 53% of schools. They are available in
teaching clinics in all schools.
|
|
Segura-Egea et al (2021)[22]
|
Spanish dental schools
|
An online survey sent via email to the undergraduate endodontic program leads in the
23 Spanish dental schools.
|
No magnification devices were used in 90% of schools.
|
|
da Costa Ferreira et al (2021)[23]
|
Brazil dental schools
|
An online questionnaire was sent to 54 dental schools in Minas Gerais.
|
70% of the universities stated that they had never included microscopes in their undergraduate
curricula.
|
|
Alobaid et al (2022)[24]
|
Saudi Arabian dental schools
|
A needs assessment survey was distributed among the deans of all the dental colleges
in Saudi Arabia.
|
33% of dental schools teach preclinical students the use of magnifying devices. During
clinical years, 53% provide training in magnification equipment.
|
|
Algahtani et al (2023)[25]
|
Saudi dentistry schools
|
An online questionnaire answered by the endodontic undergraduate programdirectors
of dental school in Saudi Arabia.
|
84% of dentistry schools did not utilize magnification.
|
|
Alsughier et al (2024)[20]
|
Undergraduate, postgraduate students, and endodontists in Saudi Arabia
|
Survey administered to undergraduate, postgraduate students, and endodontists in Saudi
Arabia.
|
45% use a magnifying device. Fourth-year students (21%), fifth-year students (28%),
and postgraduate programs (52%). All endodontists surveyed used tools for magnification.
74% of fourth-year students said surgical microscopes were the most useful. Fifth-year
students' preferences were between surgical microscopes (69%) and loupes with LED
lights (28%).
|
Abbreviation: DOM, dental operating microscope.
Discussion
This review highlights the critical role of magnification tools in enhancing technical
performance, skill acquisition, and learning experience of undergraduate dental students
during endodontic training. However, these benefits only materialize after completing
the necessary training and developing the necessary abilities.[26]
[27]
[28]
[29]
[30]
Technical Performance
Braga et al[15] reported that students who used magnifying loupes had a noticeably greater pass
percentage than those who did not. Studies by Leknius and Geissberger[13] and Maggio et al[14] found that dental magnification loupes significantly improved student performance
during preclinical dental education and were regarded as an effective adjunct by the
students who used them. This is in line with the performance difference between the
two groups. The study by Brown et al[10] that examined the use of magnification in undergraduate endodontics instruction
in the United Kingdom and Ireland is likewise in line with Braga et al's[15] findings. Those findings were aligned with a study conducted by Buhrley et al,[3] identifying the second mesio-buccal canal (MB2) to which the use of a microscope
or at the very least dental loupes was required. For the microscope, dental loupes,
and no magnification groups, the corresponding MB2 detection results were 71.1, 62.5,
and 17.2%, respectively. This further highlight how crucial it is to use magnification
to locate the MB2 canals during endodontic therapy to improve treatment results.
Wajngarten et al[16] evaluated the opinions of dental students regarding the use 2.5× magnification,
considering its usage instructions, adaptation process, benefits, or drawbacks. Because
the operational field and, by extension, dental structures are larger, most students
also stated that magnification enhanced the quality of their preclinical activities.
On the other hand, Al Agha[17] demonstrated that the amount of tooth tissue removed during an endodontic access
cavity procedure by inexperienced undergraduate students appears to be unaffected
by magnification (loupes). This could be explained by the fact that students were
not adequately trained on the use of loupes, that the loupes were of a standardized
type, and that they were more concerned with the quality of the access cavity than
the quantity of tissues removed. The group using magnifying loupes and the unaided
vision group did not significantly differ in terms of access cavity size.
-
Consistent benefits: most studies (e.g., Braga et al,[15] Wajngarten et al[16]) reported improved precision and pass rates with magnification, aligning with evidence
from Leknius and Geissberger[13] and Buhrley et al[3] on MB2 canal detection.
-
Notable exception: Al Agha[17] found no significant difference in tooth structure removal, potentially due to inadequate
training. This discrepancy underscores the importance of structured training protocols
to realize magnification's benefits.
Learning and Skill Acquisition
Regardless of the type of magnifying device employed, the results demonstrate that
the examined magnification systems had a favorable impact on students' actual fine
motor skills. The tests conducted with the naked eye were significantly faster than
those conducted with loupes when the amount of time needed to complete the Dental
Manual Dexterity Assessment was taken into consideration. These findings support the
theory that students completed the test faster because they felt safer with unassisted
vision. The use of loupes throughout the professional training phase may be significant,
according to statistics on students' assessments of their motor abilities and the
amount of time needed to finish the test. Maillet et al,[29] who stress that the use of magnifying glasses should start as soon as feasible in
undergraduate studies, support this finding. This is because an adaptation period
is an essential component of the learning process for the development of fine motor
control skills. However, the professional's visual acuity increases, and the amount
of time needed to complete clinical procedures lowers as they become more accustomed
to using magnification devices.[31]
The learning curve associated with magnification was evident. While initial task duration
increased,[18] the development of fine motor skills improved over time. Additionally, device type
influenced adaptability; Galilean systems were more beginner-friendly.[31]
[32] The nature of the Galilean system may be responsible for this adaptability.[16]
Fitts and Posner's three-stage model of motor learning[33] helps explain this skill development process. Magnification improves clarity and
focus on anatomical components, which is important for learners in the cognitive stage
who mostly rely on visual cues and teaching. Students start honing their skills through
practice as they advance into the associative stage, when magnification facilitates
more precise tactile–visual coordination. When students reach the autonomous stage,
they can carry out processes with little conscious effort, and magnification becomes
a seamless part of their workflow.
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Adaptation period: Wajngarten et al[16] demonstrated that students adjusted well to loupes, but their fine motor tasks took
longer initially,[18] a finding corroborated by Maillet et al.[29] This supports integrating magnification early in curricula to allow skill maturation.
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Device-specific effects: Galilean loupes[31] were associated with better adaptability, suggesting that device selection impacts
learning curves.
Student Confidence
Despite perceived benefits, confidence levels did not uniformly rise with magnification
use.[20] This may reflect limited clinical exposure or insufficient emphasis during early
education, again pointing to the importance of timing and training.
Educational Implications
Students should “have knowledge of the benefits and use of magnification and enhanced
illumination in endodontic practice,” according to the European Society of Endodontology's
(ESE) Undergraduate Curriculum Guidelines for Endodontology.[34] According to Cowpe et al,[35] the Association for Dental Education in Europe embraced the words used in the ESE
standards in their Profession and Competencies of the Graduating European Dentist.
Alhazzazi et al[6] assessed the awareness and attitude toward using dental magnification among dental
students and residents at King Abdulaziz University, Faculty of Dentistry, Saudi Arabia.
Most participants thought that early in dental school, instructors should encourage
the use of dental magnification. Furthermore, they thought that the fourth year was
the ideal time to present their idea. The institution where the study was conducted
grants a Bachelor of Dental Medicine and Surgery in 7 years. However, students do
not begin treating patients until their fourth year. This could be the cause of students'
apparent belief that the fourth year would be the ideal time to introduce the idea
of dental magnifications.
Brown et al[10] also examined the use of magnification in undergraduate endodontic instruction in
United Kingdom and Irish dentistry schools and determined the variables that can affect
adoption rates. Half of course leads who were asked about their course curricula said
that the official endodontic curriculum included magnification. Undergraduate students
had access to utilize DOMs at any school. Even though they are accessible, they are
not used to their full potential. They may be used for demonstration purposes, but
not necessarily used by students during completing treatment. This was reported to
be caused in part by supervisors' discomfort or lack of training with DOMs, the extra
time needed to teach while using magnification, and possibly safety concerns related
to changing students' routines. Moreover, course instructors were asked to think about
the possible obstacles to using magnification in undergraduate endodontics instruction.
Cost and employee training were mentioned by several respondents as obstacles.
Segura-Egea et al[22] assessed the state of endodontic education at the undergraduate level in Spanish
dental schools. The vast majority of dental schools in Spain did not utilize magnification
devices. Jiménez-Sánchez et al[36] analyzed the use of contemporary technologies and materials in undergraduate endodontic
teaching in Spain as well, and reached the same percentages of dental schools in Spain
utilizing magnification as Segura-Egea et al[22] On the other hand, 80% of United Kingdom dental schools incorporated magnification
in their teaching.[21]
da Costa Ferreira et al[23] investigated how much modern endodontic technology was incorporated into undergraduate
dentistry programs in a state in southeast Brazil. By viewing the root anatomy under
magnification, the operating microscope enables the endodontist to perform access
cavity preparation, chemical–mechanical preparation, retreatment, perforation treatment,
instrument removal, and apical surgery under better conditions. Nevertheless, more
than two-thirds of Brazil dental school did not incorporate DOMs into their curricula
due to their unavailability.
The integration of magnification in undergraduate endodontic education within Saudi
Arabia appears to be inconsistent and evolving. While Alobaid et al[24] reported that a modest proportion of dental schools (33% preclinical, 53% clinical)
incorporated magnification training, Algahtani et al[25] found a much lower overall utilization rate, with 84% of schools reportedly not
using magnification tools at all. This discrepancy highlights significant variation
in institutional practices, possibly reflecting differences in curriculum emphasis,
resource availability, or faculty training.
Despite these institutional gaps, there is a clear trend of increased magnification
use among students as they progress through their training. Alsughier et al[20] noted that more advanced students (fifth year and postgraduate levels) reported
higher usage rates, and all surveyed endodontists used magnification routinely. This
progression suggests that exposure to and familiarity with magnification tools particularly
loupes with LED lights and surgical microscopes grow over time, likely due to increased
clinical demands and greater awareness of the tools' benefits. Preferences also appeared
to evolve, with fourth-year students favoring surgical microscopes, while fifth-year
students showed a more balanced preference between microscopes and LED-lit loupes.
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Global disparities: while 80% of United Kingdom schools incorporated magnification
(Al Raisi et al[21]), 90% of Spanish schools (Segura-Egea et al[22]) and 84% of Saudi schools (Algahtani et al[25]) did not, primarily due to cost and training gaps.
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Student readiness: Alhazzazi et al[6] found students advocated for early exposure (Year 1), but clinical adoption peaked
in later years (Alsughier et al[20]), reflecting a mismatch between training and clinical demand.
Structured implementation techniques should be taken to guarantee the successful integration
of magnification in undergraduate endodontic teaching. A methodical, scaffolded approach
is advised. Initially, preclinical exposure can start in simulation laboratories where
students are exposed to simple magnifying devices, like LED-lit Galilean loupes. Wajngarten
et al[37] support the idea that this phase should involve instructor-led demonstrations and
guided practice to help students become familiar with ergonomics, focus adjustment,
and field lighting.
Next, magnification should be formally incorporated into clinical skills training
during the early clinical years, along with performance evaluations to monitor students'
development of skills. Teitelbaum et al[38] highlighted the significance of faculty modeling and coaching to ensure student
adoption.
Embedding these steps into a competency-based curriculum with clearly defined outcomes
related to magnification proficiency could standardize training across institutions.
Interpretation and Discrepancies
-
Conflicting results: the contrast between Braga et al's[15] positive outcomes and Al Agha's[17] null findings may stem from:
-
Task complexity: magnification's impact is more pronounced in intricate tasks (e.g.,
MB2 detection) than basic access cavities.
-
Training duration: studies with longer adaptation periods (e.g., Wajngarten et al[18]) showed better outcomes.
-
Curricular and cultural factors: United Kingdom/Ireland reported greater adoption
than Spain/Brazil, highlighting equity issues in dental education. Regarding Saudi
Arabia, its lower magnification adoption (33–53% of schools; Alobaid et al[24]; Algahtani et al[25]) compared with the United Kingdom (80%; Al Raisi et al[21]) likely reflects institutional priorities and curricular traditions rather than
resource limitations.
Implications for Dental Education
-
Curriculum integration:
-
Early exposure: introduce loupes in preclinical years to mitigate adaptation delays
(Maillet et al[29]).
-
Standardized training: develop competency-based modules (e.g., ESE guidelines) to
ensure consistent skill development.
-
Resource allocation:
-
Cost-effective solutions: prioritize Galilean loupes (lower cost, easier adaptation)
in resource-limited settings.
-
Institutional partnerships: collaborate with manufacturers to subsidize devices, as
seen in United Kingdom schools (Brown et al[10]).
-
Future research:
Conclusion
This review underscores the significant benefits of magnification tools, such as loupes
and DOMs, in enhancing undergraduate dental students' technical performance, skill
development, and confidence during endodontic therapy. Magnification improves visual
accuracy, treatment quality, and fine motor skills, particularly when students receive
proper training and early exposure.
The following standardized training protocols should be implemented by dental schools
to optimize these advantages:
-
Early exposure to magnification devices during preclinical simulation training.
-
Progressive skill development linked to motor learning principles (beginning with
Galilean loupes before progressing to surgical microscopes).
-
Faculty development programs to guarantee instructors are skilled in instructing with
magnification tools.
Global integration of magnification in dentistry education is possible despite obstacles
such as cost, inadequate faculty training, and inconsistent implementation across
institutions. To get beyond resource constraints, institutions should look for funding
methods, shared resource models, and inter-school cooperation.
Future studies should examine the following topics: cost-benefit assessments of applying
magnification at different training phases; longitudinal outcomes comparing students
taught with and without magnification over several clinical years.
Dental education around the world can progress toward the standardized and efficient
use of magnification tools to improve clinical competency and patient care outcomes
by filling in these research gaps and using structured training methodologies.
