Generative AI-Based Immersive Training for Endodontic Risk Disclosure and Informed Consent Among Dental Students

BACKGROUND AND RATIONALE:

Endodontic treatments-including root canal therapy, retreatment, and periradicular surgery-are technically demanding procedures that carry inherent risks of irreversible complications, such as instrument separation, canal ledging, pulp floor perforation, and acute flare-ups. Effective risk disclosure and informed consent (RD-IC) processes are essential ethical and legal safeguards that ensure patient autonomy, foster collaborative doctor-patient trust, and minimize medicolegal hazards. However, traditional dental education relying on passive lectures or case-based learning (CBL) fails to recreate the real-world psychological pressure and conversational fluidity needed during challenging consultations. Generative AI large language models (LLMs), such as Gemini, offer an innovative, highly scalable "safe-to-fail" platform capable of simulating adaptive patient personas with diverse emotional profiles and health literacy levels.

STUDY DESIGN AND PARTICIPANT RECRUITMENT:

This prospective, parallel-group, 1:1 randomized controlled trial was conducted at the Department of Stomatology, The First Affiliated Hospital of Hunan University of Chinese Medicine, from March to May 2026. The trial protocol strictly adhered to the CONSORT 2010 statement and CONSORT-EHEALTH 2023 extension guidelines, with ethical approval granted by the Institutional Review Board (Ethics File No. MR-43-26-046512).

A total of 96 eligible fifth-year undergraduate dental students in their clinical clerkship who had completed core endodontic didactic courses were enrolled. Participants were randomly assigned via a computer-generated random sequence to either:

1. Experimental Group (n=48): Generative AI-based Immersive Training.
2. Control Group (n=48): Conventional Case-Based Learning (CBL).

EDUCATIONAL INTERVENTIONS:

* Experimental Group: Participants completed a 1-month simulation program using the Gemini platform. The curriculum comprised six standardized, high-stakes endodontic clinical scenarios (including acute pain management, instrument separation disclosure, and pulp floor perforation). Students engaged in 10-15 minute adaptive dialogue sessions every 3-4 days. The platform utilized standardized prompt templates to deliver real-time, objective feedback on both technical completeness (risk disclosure) and humanistic communication (empathy, tone, and clarity).
* Control Group: Participants underwent conventional CBL targeting the exact same six endodontic scenarios over the same 1-month duration. Learning involved structured group case discussions, faculty lectures, and standard informed consent document reviews. Both groups had equal access to standard clinical guidelines.

OUTCOME MEASURES AND DATA COLLECTION:

Assessments were conducted at four distinct time points: Baseline (T0), Immediately Post-Intervention (T1), 1-Month Follow-Up (T2-1m), and 2-Month Follow-Up (T2-2m).

1. Primary Outcome: RD-IC Completeness Score, measured via a validated 10-item checklist covering core indications, intraoperative complications, post-op pain, prognosis, alternative plans, and compliance.
2. Secondary Outcomes:

* SEGUE Framework Scores: Assessing systematic communication competence (Set the stage, Elicit info, Give info, Understand perspective, End encounter).
* Communication Self-Efficacy Scale (SCS) Scores: Evaluating confidence across clinical communication domains.
* Communication Anxiety Scale (CAS) Scores: Assessing psychological tension and situational anxiety.
* Blinded Standardized Patient (SP) Global Ratings: External validation of clinical communication performance.
* Training Satisfaction Questionnaire: Evaluating platform authenticity, feedback quality, and user experience.
* Longitudinal Retention: Skill retention and clinical transferability evaluated at T2-1m and T2-2m.

STATISTICAL ANALYSIS:

Data analysis was conducted using SPSS 26.0 following Intention-To-Treat (ITT) and Per-Protocol (PP) principles. Group differences were evaluated using t-tests, Mann-Whitney U tests, chi-square tests, and repeated-measures ANOVA, with Bonferroni corrections applied for multiple comparisons.

• Generative AI-Based Immersive Training (Other): 1-month generative AI-based immersive training program utilizing the Gemini platform. Participants engage in 10-15 minute adaptive conversational simulations every 3-4 days covering six high-stakes endodontic clinical scenarios (such as acute pain management, instrument separation disclosure, and pulp floor perforation), receiving immediate personalized feedback on risk disclosure completeness and empathetic communication.
• Conventional Case-Based Learning (Other): 1-month conventional case-based learning curriculum targeting the exact same six high-stakes endodontic clinical scenarios. Learning involves structured case discussions, faculty-led lectures, and review of standardized informed consent templates without adaptive conversational immersion or real-time AI feedback.

Primary outcomes

• Endodontic Risk Disclosure and Informed Consent (RD-IC) Completeness Score [Immediately post-intervention (T1, at 1 month after study baseline)]: Evaluated via a validated 10-dimensional risk-disclosure checklist (10 major dimensions, each containing 10 binary scored sub-items; total possible score: 0-100). The 10 dimensions cover core treatment indications, intraoperative complications, postoperative pain, long-term structural defects, poor prognosis, anatomical variations, sequential restorative treatments, anesthetic \& material allergies, systemic-disease-related complications, and treatment-failure risks from poor patient compliance. Higher total scores represent greater technical accuracy and comprehensiveness of endodontic preoperative risk disclosure and informed-consent documentation.

Secondary outcomes

• SEGUE Framework Doctor-Patient Communication Competence Score [Immediately post-intervention (T1, at 1 month after study baseline)]: Evaluated using the SEGUE framework checklist, assessing 5 communication domains: Set the Stage, Elicit Information, Give Information, Understand Patient Perspective, and End the Encounter. Total median scores range from 0 to 25, with higher scores reflecting superior systematic doctor-patient interaction skills.
• Clinical Communication Self-Efficacy Scale (SCS) Score [Immediately post-intervention (T1, at 1 month after study baseline)]: Measures students' confidence across 4 domains: Information Gathering, Clinical Information Delivery, Emotional Empathy, and Conflict Management/Closing. Scores range from 20 to 100, with higher scores indicating higher self-efficacy.
• Communication Anxiety Scale (CAS) Score [Immediately post-intervention (T1, at 1 month after study baseline)]: Evaluates clinical communication anxiety across 4 sub-domains: Situational Tension and Physical Anxiety, Professional Self-Doubt and Worry, Endodontic Risk Disclosure Anxiety, and Communication Burden and Avoidance Tendency. Scores range from 20 to 100, with lower scores indicating reduced clinical communication anxiety.
• Blinded Standardized Patient (SP) Core Clinical Communication Competence Score [Immediately post-intervention (T1, at 1 month after study baseline)]: External assessment rated by blinded standardized patients across 5 core clinical domains: Reception Etiquette, Standardized Inquiry, Risk Informed Consent Communication, Emotional Empathy, and Closed-loop Guidance. Total scores range from 0 to 100, with higher scores reflecting better clinical communicative performance.
• AI Simulation Teaching Experience Scale Score [Immediately post-intervention (T1, at 1 month after study baseline)]: Assesses student satisfaction with the educational intervention across 5 sub-scales: Platform Operation, Simulation Scene Authenticity, AI Real-time Feedback Quality, Perceived Ability Improvement, and Recognition of New Teaching Mode. Total scores range from 20 to 100, evaluated against a theoretical neutral midpoint of 50.
• Long-term Retention Score of Endodontic Risk Disclosure (1-Month Follow-Up) [1-month post-intervention follow-up (T2-1m, at 2 months after study baseline)]: Evaluates retention of communication skills 1 month post-intervention (T2-1m) across 5 sub-items: Basic Disease Communication, Intraoperative Risk Disclosure, Postoperative Risk Communication, Empathetic Alternative Plan Communication, and Closed-loop Consent Procedure. Total scores range from 0 to 100.
• Long-term Retention Score of Endodontic Risk Disclosure (2-Month Follow-Up) [2-month post-intervention follow-up (T2-2m, at 3 months after study baseline)]: Evaluates long-term durability and resistance to skill decay 2 months post-intervention (T2-2m) across the same 5 risk disclosure sub-items. Total scores range from 0 to 100.

Sex: All, ages: 18 Years to 25 Years, accepts healthy volunteers

Inclusion Criteria:

* Fifth-year undergraduate dental students undergoing clinical clerkship at the Department of Stomatology, Hunan University of Chinese Medicine.
* Completed all core didactic and theoretical courses in endodontics.
* Entered the early stage of clinical rotation.
* Provided signed voluntary informed consent to participate in the trial.

Exclusion Criteria:

* Prior experience with specialized clinical communication simulation or specialized AI communication training.
* Presence of unavoidable schedule conflicts during the study period.
* Factors affecting student eligibility to complete the full training and evaluation process.