This survey study was undertaken at the West China School of Stomatology of Sichuan University. This school is recognized as a pioneer of modern dental education in China and has consistently ranked first in stomatology evaluations in mainland China [31]. The dental science program at the West China School of Stomatology is the top-ranked discipline among all dental colleges and universities, according to the Ministry of Education of mainland China. The undergraduate dental science (5-year) program is intended to nurture students with basic medicine and clinical medicine knowledge, train students with basic theories and practical skills of stomatology, and qualify students with solid expertise on the diagnosis, treatment, and prevention of common and frequently occurring oral diseases. The course structures and learning modes in this school are considered to represent the highest level of undergraduate dental education in China.

The survey recruited final-year undergraduate dental students who majored in dental science at the West China School of Stomatology of Sichuan University during the end of the fall semester of academic years 2020-2021 and 2023-2024, as representative time points for COVID-19 (December 2019-May 2023) and post–COVID-19 (May 2023), respectively. In total, 248 and 226 final-year undergraduate dental students enrolled in the fall semesters of the academic year 2020 to 2021 and the academic year 2023 to 2024 were invited to participate in the survey. The inclusion criteria were students who (1) were enrolled in the undergraduate stomatology (5 years) program at the West China School of Stomatology of Sichuan University; (2) had completed all previous comprehensive theoretical and practical training courses in the past 4 years; and (3) had smartphone, tablet, and laptop devices with internet access during the data collection process. The exclusion criteria were students who (1) were transfers and (2) were on long-term leave or had dropped out during the study periods (COVID-19 period: December 2019 to May 2023; post–COVID-19 period: May 2023 onward).

Participants accessed their blended learning experiences during their final-year study in the fall semester of the academic year 2020 to 2021 and the academic year 2023 to 2024. Courses in the undergraduate stomatology (5 years) program, which is one of China’s double first-class disciplines and is jointly run with the West China Hospital of Stomatology of Sichuan University, were evaluated in this study. This program aims to cultivate talents who have basic medical theoretical and clinical knowledge; master oral medicine theories and clinical operation skills; are engaged in the national medical practitioner qualification certification; and have good professionalism in oral clinical diagnosis, treatment, and prevention. The curricula that were evaluated in this survey consisted of 49 courses divided into 4 types, namely, general courses (10/49, 20%), specialized foundation courses (22/49, 45%), specialized courses (14/49, 29%), and practical courses (3/49, 6%).

This study used a self-administered, anonymous, electronic survey, including a survey invitation letter, participant informed consent, a questionnaire of 20 questions, and a free-response item. The first section of the questionnaire collected information on students’ majors and year of study, their self-perceived knowledge levels for blended learning, and the frequency with which they reported using blended learning in their studies. The second section evaluated the types of curricula using blended learning and the detailed implementation of the learning processes. In the third section, the items measured students’ satisfaction with blended learning and factors influencing their satisfaction [32,33]. The following section assessed students’ perceptions of the strengths of blended learning compared with online or offline learning and evaluated their desire to engage in blended learning. The final section asked about factors that might increase or decrease students’ potential engagement [9]. The free-response item was included to gather rich insights into students’ thinking about blended learning. Items assessing students’ self-perceived knowledge levels of blended learning were rated using a 4-point Likert scale (ranging from not knowledgeable to very knowledgeable) [32]. Items assessing students’ satisfaction with blended learning were rated using a 5-point Likert scale (ranging from very dissatisfied to very satisfied) [34]. Items assessing students’ desire to participate in blended learning were rated using desire as a predictor of engagement. Items assessing factors influencing students’ desire to engage in blended learning were evaluated using multiple-choice question options.

The survey was developed on a web-based survey platform, WJX.cn, in mainland China, based on a skip-logic design. The items were developed by a panel of 12 experienced educators, student representatives, and academic affairs experts and were piloted on 10 subjects for 2 rounds without iterative revision. The online survey was conducted following the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines.

The survey recruitment was conducted during 2 separate 2-week recruitment periods (January 18 to January 31, 2021, and December 27, 2023, to January 10, 2024). The survey link was included in an invitation letter and was distributed to students via QQ, which is an online platform well accepted by undergraduate students for its instant messaging and online organizing functions [35]. The response settings were rigidly specified so that a respondent could submit only 1 response, and up to 3 reminders were sent to nonresponders during the recruitment period.

All statistical analyses were performed using SPSS software (version 22.0). The response rates included only fully completed surveys from respondents. Descriptive statistics for each outcome variable were reported as mean, mean difference (MD), and standard deviation (SD) for continuous quantitative variables and frequencies (or percentages) for categorical variables. We conducted the Shapiro-Wilk normality test and found that the student satisfaction data approximately followed a normal distribution across outcome variables (overall blended learning, individual curricula, and specific learning activities). Then, the 1-tailed t test was adopted as a parametric test to examine differences between groups by comparing the overall -satisfaction group, the high satisfaction group (HSG, defined as satisfaction responses as very satisfied and satisfied), and the low satisfaction group (LSG, defined as satisfaction responses as very dissatisfied, dissatisfied, and neutral) with a 95% CI. Pearson correlation analysis was used to examine factors associated with higher satisfaction from respondents. The chi-square test, a common nonparametric test for data not assumed to be normally distributed, was used to compare the strengths of blended learning with offline or online learning only between different groups.

The survey was approved by the Academic Affairs Division, West China School of Stomatology, Sichuan University Institutional Review Board (WCHSIRB-D-2024-481). The electronic survey invitation letter included a description of the study’s objectives and procedures, informed participants that participation was voluntary and anonymous, and clarified that the survey results would be used for research purposes only. Informed consent was obtained from participants upon survey submission. No compensation was given for participating in this study.

This study demonstrates that final-year undergraduate dental students had a generally satisfied attitude toward blended learning in the COVID-19 and post–COVID-19 years. Students acknowledged the strengths of blended learning in multiple aspects compared to online or offline learning only. Meanwhile, students desired to engage in blended learning and reported factors that might influence their potential engagement. These findings reveal students’ self-reported satisfaction and perceptions regarding blended learning for undergraduate dental education and provide practical clues for enhancing student engagement in blended learning in the circumstance of the COVID-19 pandemic and beyond.

At its peak, the COVID-19 pandemic significantly impacted higher education by necessitating rapid shifts to online or blended learning in health professional training [7,9,36]. Participants generally acknowledged that the diverse methodologies in online-based learning during the COVID-19 pandemic advanced the modernization of health professional education [37]. In addition, comparable or even greater effectiveness for knowledge acquisition than nonblended learning has been observed in health professionals, although heterogeneity should be noted [38]. Similar positive effects of blended learning have been reported in health professions students for learning effectiveness [39], graduate medical students for knowledge gain [40], and undergraduate medicine and nursing students for knowledge outcomes and clinical skills training [7,41]. Serving as one of the most prevalent teaching approaches for medical education during the pandemic, blended learning encountered challenges such as students’ limited acceptance of technology-assisted learning, difficulties in student engagement during the learning process, and issues related to cognition and retention [42]. Moreover, the sudden transition of medical education to online-only or blended learning modes during the pandemic might interrupt academic interactions and trigger unstructured learning patterns among health professional students and arouse their need for retaining certain course components, such as practical training in traditional face-to-face learning [43].

In our survey study, more students showed a generally satisfied attitude toward blended learning in 2020 compared to 2023 (Table 2). Other studies have shown that students’ age, computer experience, and technology acceptance might affect their satisfaction with online learning [44,45], while failure to incorporate these aspects in our survey might bias the results. In fact, final-year dental students complete most of their theoretical and practical studies during their junior year or earlier, making them familiar with online learning environments and technology for blended learning, which helps minimize bias in our study. Notably, students expressed the lowest degree of satisfaction toward practical courses in both 2020 and 2023 (Table 2), consistent with the finding that the number of students who desired to engage in practical courses involving blended learning was the least among all curriculum types in both years (data not shown). However, in another study assessing student perceptions of blended learning in practical training in orthodontic education, students expressed general acceptance and a preference for engagement in the blended learning mode compared with both traditional solid models and e-models [18]. Specifically, the blended learning mode that combines electrical 3D simulation models with traditional plaster models cultivates critical thinking and haptic sensitivity to facilitate clinical practice [18]. Another retrospective study concluded that the integration of a flipped classroom approach into blended learning in a dental anatomy course could effectively improve students’ scores in practical assessments, although not in theoretical assessments [46]. These studies support the adoption of blended learning in practical training for undergraduate dental education. Moreover, the learning of experiential forms of knowledge is also important for dental skills [47,48]. By contrast, in the COVID-19 pandemic context, the emphasis on patients’ knowledge of dental emergencies, disease transmission, and needed preparations underscored the need for dental students to enhance their professional preparedness and knowledge for clinical practice [38]. This might fuel senior dental students’ aspiration to acquire clinical skills, particularly during the post–COVID-19 period. Future instruction on the rationality of course design, the availability of reliable online resources, and the delivery of in-class activities is necessary for the implementation of blended learning in dental courses with practical components, improving learner acceptance and performance outcomes.

In our study, students showed the lowest satisfaction for teacher-student interactions in both 2020 and 2023 (Table 2), and teacher-student interactions were identified as a key factor influencing student engagement in blended learning (Multimedia Appendix 3). According to the social constructivist theory [49], interactions between a student and their teachers and peers during blended learning could stimulate effective learning and thus improve student learning [50]. Blended learning can also integrate the advantages of synchronous teacher-student interactions with asynchronous time and space flexibility to foster the engagement of students and teachers in the learning process [51,52]. Indeed, teacher-student interactions contribute to improved student engagement and satisfaction with blended learning compared to online learning and face-to-face learning [50]. During the COVID-19 pandemic, students reported insufficient interactions with teachers for preclinical practice in dental education, and such reduced teacher-student interactions partially impacted students’ overall satisfaction with online learning-involved processes [9,50,53]. Barriers such as challenges in selecting helpful peers, limited and delayed teacher feedback and support, as well as difficulty in discerning relevant information, particularly in asynchronous online environments, might lead to students’ dissatisfaction with teacher-student interaction experiences in blended learning.

Students greatly appreciated the strengths of blended learning over online or offline learning only (Table 3). In the past decade, online learning resources and platforms have substantially facilitated the successful implementation of blended learning in higher education [54]. During the COVID-19 pandemic, more high-quality online courses were freely developed, opened, and shared among different schools to enhance public accessibility for educators and students [55]. In recent years, it is encouraging that more high-quality online learning platforms with communication components have been available for web-based courses in dental education, such as Rain Classroom [56] and PMPHMOOC [57]. These platforms could be accessed by students and teachers on campus or remotely via mobile devices, such as laptops, tablets, and phones [9]. Moreover, social software tools, such as Tencent QQ chat groups [9] and WeChat apps [58], also demonstrate an educational function by promoting multidirectional interactions, including teacher-student interactions, even during the COVID-19 pandemic [11]. Although these platforms are mostly limited to China and might not be applicable to other countries, the fast-growing evolution of these online learning platforms and social tools is progressing toward meeting the needs of dental students and educators in the COVID-19 and post–COVID-19 periods.

Students expressed a desire to engage in blended learning in both 2020 and 2023 and reported several factors that might influence their potential engagement. More than half of the students indicated the importance of tech for blended learning in both years (Multimedia Appendix 3). As mentioned earlier, much effort is needed to facilitate the implementation of higher education due to the COVID-19 pandemic [59]. However, the availability of newly developed educational resources is still limited. Moreover, their applications and adaptations to a wider range require more time and practice [35,60]. Previous studies have shown a strong relationship between the learning environment and student learning behaviors, self-perceived satisfaction, and academic performance [61-64]. As a well-established element highly susceptible to the environment, self-regulated learning imposes higher standards for students to adapt to the inevitably varied COVID-19 pandemic and postpandemic world than before [19,36]. Efforts have been made to cultivate self-regulated skills in students for a web-based environment, such as the provision of tutorials before starting a course or the supply of real-time skill guidance within a course. Our findings also suggest that with the incorporation of blended learning, a significant number of students viewed the impact of the development of the learning environment positively when faced with the unprecedented COVID-19 and post–COVID-19 periods.

There are several limitations of this study. First, the survey was performed in a single dental school and might not reflect the blended learning experiences of other schools. Second, our survey did not record students’ health status during the COVID-19 and post-COVID-19 periods.

This survey study demonstrates that final-year undergraduate dental students are generally satisfied with blended learning in both the COVID-19 and post–COVID-19 years. Although students prefer to engage in blended learning compared with online or offline learning only, their desire to participate might vary depending on multiple factors. Dental schools, policy makers, and educators could increase students’ engagement in blended learning by incorporating more teacher-student interactions, establishing standardized assessment mechanisms, providing dedicated learning materials and platforms, and promoting self-regulated learning among dental students. The COVID-19 pandemic has raised an alarm for dental education to reform into a more flexible and adaptable mode, and this survey provides clues for developing a new face of blended learning–involved dental education in the context of the pandemic and beyond.