## 4 Discussion  
Learning practical skills in endodontics is considered to be one of the most challenging tasks in undergraduate dental education [26], primarily due to marked anatomical variations in natural teeth. Access cavity preparation is a fundamental skill in endodontics and \begin{table}
\begin{tabular}{l l} \hline \hline
**Participants’ Recommendations** \\ \hline \(\bullet\) & It should start before pre-clinical practice on mannequins, preferably in Year 2. \\ \(\bullet\) & Diverse types of root canal anatomical models might be introduced into the software. \\ \(\bullet\) & Software should be improved (e.g., the negotiation of root canal orifices, irrigation of root canals, and water running through air motor handpiece are not available) \\ \(\bullet\) & Automated feedback is insufficient, additional feedback by the facilitator might be helpful \\ \hline \hline \end{tabular}
\end{table} 
Table 4: Recommendations for Future Development of Virtual Reality Dental Simulation in Endodontics. Figure 1: Mean score and confidence intervals by question and school. requires an accurate balance between conservation of healthy tooth structure and preparing a cavity which is suitable to gain a straight-line access. Preclinical training in endodontics most is frequently delivered using acrylic and/or natural teeth using mannequin models. Difficulty in negotiating the complex root canal anatomy, particularly in multi-rooted teeth, has been reported as a common challenge by undergraduate students [27]. The introduction of VRDS has offered an innovative option to visualize root canal anatomy and learn endodontic access cavity preparations [28]. Notwithstanding the initial cost, use of VRDS presents several advantages including the option to repeat the exercises multiple times without any expenditure on materials or fear of making an error. Training of VRDS is environmentally friendly as it does not produce any waste. Additionally, there are options to build additional cases in the VRDS library to enhance student training including simulation of real patient cases [29; 30; 31]. The present study focused on the learning experiences of undergraduate students in endodontic access cavity preparations using conventional models as well as VRDS at two institutions. Although different VRDS systems were used by the participating institutions in this study, both systems incorporated a touchscreen, dental handpiece, space mouse, dental mirror, and speed pedal. The virtual models of both systems also simulated dental tissues (enamel, dentin, pulp) pulp chamber, pulp floor, as well as dental caries. This study explores the impact of VRDS on endodontic access cavity preparations in undergraduate dental education programs. A vast majority of the participants shared positive perceptions and experiences with VRDS training suggesting that it can certainly complement pre-clinical training using acrylic and natural teeth. However, in its present form, VRDS cannot replace training on conventional dental models, which simulate clinical endodontics on real patients more closely. These findings corroborate previous studies [12; 32; 33]. However, in contrast to previous study [4], a high proportion of the participants felt that access cavity preparation on VRDS closely matched the same on natural as well as acrylic teeth. The virtual tooth closely simulated the differential hardness of enamel, dentine, and pulp, which allowed participants to feel tooth cutting and drop in the pulp chamber in a comparable way as experienced on natural and acrylic teeth. These differences may, at least in part, reflect improvements in haptic feedback provided by VRDS equipment as some of the previous studies reporting lower satisfaction with the quality haptic feedback were conducted several years ago. The participants in this study provided a few recommendations to further improve the VRDS technology including improvements in software to capture variations in root canal anatomy, options to negotiation root canal orifices, and practice irrigation.