Introduction

The COVID-19 pandemic profoundly trans- formed numerous aspects of sectors and fields, including the educational sector. The social distancing measures implemented due to the pandemic led to an abrupt transition to virtual education in many countries, posing significant challenges for both students and teachers (¹). Online education was already in use in some university contexts as a complementary tool before the pandemic, but its implementation was neither widespread nor mandatory. The COVID-19 outbreak marked a turning point in this context, forcing institutions to rethink their pedagogical strategies and rely on technology as the primary means to ensure educational continuity (²).

The shift to virtual learning had varied implications depending on the academic discipline. In fields with a strong practical component, such as health sciences, adapting to online education presented unique challenges. The virtualization of courses not only affected the delivery of theoretical content but also posed difficulties for practical instruction and the assessment of clinical skills (³, ⁴). Digital platforms do not always provide adequate tools to replicate the practical instruction essential in fields like dentistry. This forced programs to modify their assessments and competency development processes, raising concerns about students' acquisition of technical skills (⁵).

Some studies indicate that online education can either increase or decrease learning effectiveness, depending on factors such as available technological infrastructure, course design, and institutional support (⁶). Additionally, González et al. suggests that while some students may quickly adapt to online education, others may face significant difficulties, as reflected by lower approval rates and overall academic performance (⁷).

The dentistry program of the University of Costa Rica (UCR) rapidly adapted its teaching methods; strategies such as recording clinical simulations, using interactive software, and providing support through online platforms were implemented to allow students to follow practical steps virtually. However, the effectiveness of these measures was not uniform, highlighting the need to analyze whether these actions impacted course approval rates and how the quality of learning was perceived in specific student cohorts.

In the Faculty of Dentistry (FOd, by its acronym in Spanish) at UCR, the effects of course virtualization on approval rates, academic performance, and student retention, all crucial to understanding the impact of the pandemic on dental students' education, have not been analyzed. Therefore, this study aimed to determine the effect of the COVID-19 pandemic on the educational indicators of student cohorts who entered the Dentistry Career at UCR between 2015 and 2021, providing information to the Academic Unit for planning strategies that enhance student performance.

Methodology

Results

A total of 522 student records with complete data from 2015 to 2021 were reviewed. The analysis of the sociodemographic distribution of students enrolled in the dentistry program revealed that 70% of the students were women. Most of the students (around 97%) were Costa Rican, with a small proportion of foreign students (3%).

Regarding the age of entry, the largest group consisted of students between the ages of 19 and 23, representing 61% of the total number of students. Moreover, 55% of the students came from public high schools, 66% were from the GAM, and 95% were single and did not have children during his years of study. Marital status and parenthood could not be determined for 18 students, as this information was not available for foreign students in the Civil Registry data (Table 1).

Terminal efficiency was zero, as the suspension of clinical courses in 2020 prevented students from the 2015 and 2016 cohorts from graduating within the proposed 12 terms of the dentistry curriculum at FOd-UCR. Only some of the students who entered the courses in 2015, 2016, and 2017 had managed to complete the program. Later cohorts, specifically those from 2018 onwards, had not yet reached the end of their training.

The analysis of the curriculum cycle in which students were enrolled revealed that most students were in cycles 7 and 8, representing 34.7% of the total; cycles 9-10 accounted for 24.5%, and cycles 3-4 for 18.4%.

The student dropout rate was 24.5%. The first semester had the highest dropout rate (43%) in both the pre-pandemic period and the pandemic period, followed by the second semester (25%). As semesters progressed, dropout rates decreased, except for semesters nine, eleven, and twelve, where no students dropped out (Table 2).

In terms of academic delay, all cohorts from 2015 to 2019 had students with delays in their studies. In contrast, in 2020 and 2021, a group of students with no delay was observed (Table 2).

As a result of the COVID-19 pandemic in 2020, all theoretical courses and some laboratory courses of the dentistry program at FOd-UCR were virtualized, while clinical courses were suspended. In 2021, clinical courses were reinstated; however, theoretical courses remained virtual, except for those with a laboratory component, such as dental anatomy, operative dentistry, orthodontics laboratory, and fixed and removable prosthodontics. By 2022, all courses in the curriculum were conducted in person, with a minimal virtual component.

The results showed a notable increase in academic performance during the pandemic in several of these courses. In particular, the pass rates for Intensive General Chemistry, Elementary Mathematics, Fundamentals of Physics, and Histology saw a statistically significant increase. However, in the case of General Biology, although the pass rate increased, the difference was not significant. Additionally, the first-attempt pass rates of Dental Biochemistry and Human Physiology did not increase during the pandemic period, remaining at similar levels to those recorded in the pre-pandemic period (Table 3).

Most students who had failed Intensive General Chemistry, Elementary Mathematics, and Fundamentals of Physics four or more times in the in-person modality had passed when these courses were virtualized.

No statistically significant difference was observed between the pass rates of the courses specific to the FOd-UCR, before and during the pandemic. Pediatric Dentistry, Dentistry and Orthodontics, Restorative Sciences, and Endodontics remained the courses with the lowest pass rates among the clinical courses, both before and after the clinics were reinstated (Table 4).

Discussion

The COVID-19 pandemic affected the academic performance of students in the dentistry program at FOd-UCR in various ways. Among the sociodemographic characteristics analyzed, it was evident that the majority of students were female. The predominance of females in the student population reflects a global trend in health professions, where women tend to be the majority, possibly due to factors such as professional flexibility and interest in fields related to people's well-being (⁹, ¹⁰).

Additionally, a significant number of students entered the program at 18 years old or younger, particularly in the most recent cohort. This could be due to modifications in secondary education processes made in 2018, where students were allowed to take the national high school exams in subjects they had passed in their final year even if they had failed other subjects that were not evaluated in these exams; before this change, 15% of students each year could not take the exams as they failed one or more subjects (¹¹).

On the other hand, the pandemic had an uneven influence on educational indicators such as terminal efficiency, academic delay, dropout rates, and academic performance. It severely affected terminal efficiency, as no student from the Faculty of Dentistry in the 2015, 2016, and 2017 cohorts graduated within the six years established by the curriculum plan. This was attributed to the suspension of clinical courses that started on March 13, 2020. Similar results were observed in other institutions, such as the Technological Institute of Zacatecas, where terminal efficiency fell from 58.18% in 2019 to 53% in 2020 (¹²). At the Universidad Veracruzana, the Faculty of Mechanical Engineering and Naval Sciences saw a decline in terminal efficiency from 64.7% before the pandemic to 22.8% in the 2021-2022 period, although it recovered to 63.9% in 2022-2023 (¹³).

There was a significant decrease in graduation rates in the early years of the pandemic. In 2020, there were no graduations at FOd-UCR, a trend similar to that observed at the Faculty of Dentistry of the Universidad Autónoma del Estado de México, where there were no graduations during the 2019-2020 and 2020-2021 periods (¹⁴). However, at other institutions such as the Technological Institute of Zacatecas, in engineering, administration, and architecture programs, although graduation rates declined, they did not stop entirely; in 2019, there were 519 graduates, while in 2020 the number dropped to 272 (¹²).

During the pandemic, dropout rates were primarily concentrated in the first two academic cycles, similar to a situation reported in a cohort study conducted from 2007 to 2014 at FOd-UCR (⁸). This can be associated with the fact that these cycles contain the most service courses in the entire curriculum, and these were the courses that students failed most frequently. Dropout in these cycles also follows a common pattern in higher education, where many students face significant challenges during their adaptation to university life, which can overwhelm some of them (¹⁵). According to a study by van Rooij et al. (2018), factors such as lack of self-regulation and dissatisfaction with the academic program also play a crucial role in this process, affecting students' ability to adapt to new university environments (¹⁵). A systematic review mentioned that during the COVID-19 pandemic, these challenges intensified due to the sudden virtualization and suspension of in-person activities, which resulted in increased academic stress and difficulties in continuing studies. Furthermore, forced virtualization exacerbated these challenges, increasing academic stress and affecting the performance of students who were unprepared for remote learning, as well as some professors who were not trained in new technologies (¹⁶).

Only in the cohorts of students from 2020 and 2021, who enrolled in the program when courses had been virtualized, was there a group of students who did not show any delays. This could be associated with research showing that online education can also be very effective, especially when appropriate technologies are used and basic student needs, such as their sense of autonomy and competence, are met. This not only helps maintain their motivation but also encourages them to persist in their studies and achieve their goals (¹⁷, ¹⁸).

In the other cohorts, there were students with delays. These cohorts had started in-person classes before the pandemic, took virtual classes during the pandemic, and were receiving in-person classes again at the time of the study. These changes in lesson delivery, combined with the fact that students from the 2015, 2016, and 2017 cohorts could not enroll in some clinical and laboratory courses, affected their academic performance.

This delay could also be related to studies showing that although the initial virtualization of courses during the pandemic was helpful, things did not return to normal when in-person classes resumed (¹⁹). Many students had difficulties readjusting to the in-person format, which affected their academic progress. Aristovnik et al. (2023) observed that this transition can lead to a decrease in academic performance, as students lose the flexibility and autonomy offered by the virtual environment, thus facing greater challenges in meeting the demands of in-person classes (²⁰).

Moreover, a notable increase was observed in the number of students in cycles 7-8 and 9-10. The accumulation of delayed students could be attributed to educational interruptions, as they could not complete practical and clinical courses in person during that period, while another group of students progressed where previous courses were virtualized. According to UNESCO reports, this situation is not unique to the dentistry program, as many universities face the same challenge, accumulating students from different generations in the same classrooms (²¹). This highlights the need to develop academic support strategies that facilitate student progress and retention in complex educational contexts where cohorts from different years are forced to share space and educational resources.

Academic performance in some service courses in the dentistry program was also affected by the shift to virtual teaching. Analysis of first-attempt pass rates during pre-pandemic and pandemic periods revealed that many courses experienced a significant increase in academic performance. Courses such as Intensive General Chemistry, Elementary Mathematics, Fundamentals of Physics, and Histology showed notable improvements, suggesting that the transition to online education may have facilitated more effective learning for students. This phenomenon was also observed in other institutions, such as the Instituto Tecnológico de Celaya, where failure rates in differential calculus dropped from 50% in 2019 to 23% in 2020 (²²).

Interestingly, in courses such as Intensive General Chemistry and Elementary Mathematics, some students who had failed up to four times in person passed when they attended the courses virtually. This could be related to changes in educational methodology, where virtual teaching and modifications in evaluations improved student performance, especially for those repeating courses (²³).

On the other hand, the Dental Biochemistry and physiology courses did not show improvements in pass rates during the pandemic, maintaining levels similar to those previously observed. This suggests that some courses may have been less susceptible to changes in educational methodology or that the factors determining academic success in these courses are more complex. This was also evidenced in the basic algebra preparatory course at the Autonomous University of Zacatecas, where statistically significant differences were not observed in failure rates between the virtual modality in 2020 and the in-person modality in 2019 (²⁴). This aligns with studies that suggest virtual teaching may not be equally effective for all courses, especially those requiring practical skills (²⁵, ²⁶).

Some clinical courses among the specific courses in the dentistry program maintained low pass rates. This could be associated with what Machado et al. (2020) (²⁷) indicated, that although digital platforms allow for the continuity of theoretical instruction, the lack of direct clinical interaction and opportunities to practice with patients hinder the development of essential practical competencies for dental training. The abrupt transition to remote education during the pandemic left many students with less confidence in their clinical skills, as indicated by the study conducted at the University of Jordan, where students perceived distance education as an inadequate substitute for in-person clinical training, with 87% of the participants reporting that their clinical training was the most negatively affected experience during the lockdown (²⁸).

Another factor that may have influenced the failure of some clinical courses during the COVID- 19 pandemic was the availability of patients for students. This can be associated with the fear of contagion, which led many patients and parents to postpone or cancel their dental visits and those of their children, even when strict biosecurity measures were applied. Studies conducted in Italy revealed that the perception of risk and anxiety associated with the virus influenced the decision to postpone appointments more than direct economic difficulties arising as a consequence of the pandemic (²⁹). In contexts such as Scotland, mobility restrictions and the temporary closure of dental services for non-urgent procedures resulted in a drastic decrease in pediatric patient care, which only began to slowly reverse with the gradual reactivation of health services (³⁰).

One of the strengths of the current study is that it is the first to demonstrate the effect of the COVID-19 pandemic on educational indicators, with the virtualization of most courses in the dentistry program at FOd-UCR. Additionally, the results indicate that there continues to be a significant difference between the pass rates of service courses and those specific to FOd-UCR when courses are taught in person and virtually.

Among the limitations of this research is that it was not possible to determine whether the socioeconomic status of students (which was not included in the SAE) was related to delays and dropout rates. An analysis of this variable would have yielded interesting findings, especially since during the pandemic, the economic income of many families was affected, as demonstrated by research conducted with UCR students from various fields in 2020, where 52% of respondents indicated that their families had experienced unemployment issues, 66% had seen a reduction in work hours, and 77% had suffered a decrease in economic income (³¹).

Future research plans include studies with private universities in Costa Rica that offer the Dentistry Bachelor's Program to determine the degree of course virtualization and analyze whether pass rates, academic delay, and dropout rates are similar in both public and private education.

Conclusions

The COVID-19 pandemic had a varying impact on educational indicators such as terminal efficiency, dropout rates, and academic delay. Educational virtualization, which was implemented during the COVID-19 pandemic, showed varying effects depending on the discipline. In theoretical subjects such as Intensive General Chemistry and Elementary Mathematics, virtualization improved academic performance. However, in courses with a practical component, such as human physiology, students faced greater difficulties adapting to remote learning. This suggests that the effectiveness of virtual teaching varied according to the nature of the course.

These findings highlight the importance of developing pedagogical strategies tailored to the characteristics of each discipline. While virtualization proves effective in certain contexts, it cannot completely replace in-person training in areas that require intensive practical instruction. Therefore, it is crucial to balance the use of digital tools with in-person methods to ensure a comprehensive and effective education.

Author contribution statement

Conceptualization and design: N.G.M., A.G.F. and C.C.S., and N.G.M.

Literature review: N.G.M., A.G.F. and C.C.S.

Methodology and validation: N.G.M., A.G.F. and C.C.S.

Formal analysis: N.G.M., A.G.F. and C.C.S.

Research and data collection: N.G.M., A.G.F. and C.C.S.

Resources: N.G.M., A.G.F. y C.C.S.

Data analysis and interpretation N.G.M., A.G.F. and C.C.S.

Original draft preparation and writing: N.G.M., A.G.F. and C.C.S.

Writing, review, and editing: N.G.M., A.G.F. y C.C.S. Supervision: N.G.M., A.G.F. and C.C.S.

Project administration: N.G.M., A.G.F. and C.C.S.

Funding acquisition: Not applicable for this study.