Oral diseases are significant health problems at the global level and have both high prevalence and adverse effects on individuals and societies. In general, more than 3.5 billion people around the world suffer from oral diseases.^[1] These lesions are among the most challenging oral conditions in public health.^[2] Since they diminish health-related quality of life by causing local discomfort and pain, as well as interfering with speaking, swallowing, chewing, and maintaining oral hygiene.^[3] These disorders can be chronic and progressive, developing in childhood and continuing into adulthood.^[1]

The oral cavity must be examined for malignant changes through exact clinical examinations and routine screening. These changes should be easily detected in the early stages to lead to more effective disease management. Despite easy access to the oral cavity for examinations, oral cancer remains a disease with high mortality. Early diagnosis and treatment decrease patient morbidity and mortality; however, most oral cancers are diagnosed at late stages, even in developed countries.^[4] When these lesions occur and are diagnosed at early stages, simple treatment is needed, and subsequently, the defects and disfigurement are minimized.^[5]

Patients with oral lesions are often examined by general dentists for the first time; therefore, general dentists play a vital role in diagnosing oral cancers in the early stages.^[6]

Oral pathology is a specialty of dentistry that addresses the diagnosis and management of oral and maxillofacial lesions. The knowledge of pathology bridges the gap between basic and clinical dental science, which is essential in training students to correctly diagnose the cause and mechanisms of oral diseases.^[7] This knowledge is critical for diagnosing and curing oral mucosa lesions, including benign, premalignant, and malignant lesions.^[8]

According to medical science professors and students, this knowledge is considered one of the most challenging subjects in the educational curriculum. Moreover, it is neglected by many dentists because they are not ordinarily involved with oral pathology.^[9] The nature of pathology knowledge, insufficient experience in diagnosing oral lesions, and some teaching methods, such as lecture-based methods, are the causes of the inherent challenges of this knowledge for medical students. According to medical students’ experiences, the main reasons for the difficulty of studying pathology are the extensive terminology of lesions, the large volume of information materials, and the inadequate time allocated to this subject in the educational curriculum.^[10,11]

Considering the technological advances and changes in the digital world in recent decades, the need to change traditional learning methods or to accompany novel methods is expected. In this regard, learning applications are suggested as effective educational tools that engage students in purposeful, entertaining, and motivating activities in a safe environment. In addition, it provides a platform where social interaction and bonding among students are promoted, thus increasing students’ connection with the educational environment and the desired subject.^[12] Web-based applications are known as teaching methods for multimedia.^[13] Traditional tutorials are teacher-centered, presenting a summary of concepts. Sometimes, these methods are tedious and less practical; students’ participation in these methods is inadequate, and critical thinking or the application of the acquired knowledge might be ignored.^[14] However, applications, as educational tools, include innovative, challenging, and student-oriented methods. Combining digital educational applications with current medical science is a newly designed method for students in healthcare fields.^[15] As an educational strategy, these applications have the potential to improve students’ performance by improving knowledge, self-learning skills, and attitudes.^[16]

An increase in problem-solving skills and critical thinking has been observed through the use of these kinds of applications.^[17] These applications provide an entertaining, educational environment in which students are faced with various questions.^[18] With this method, students can design hypotheses and provide solutions where they can learn from their errors without fatal results for actual patients.^[19] Moreover, these applications make learning enjoyable, challenging, and stimulating, and provide the opportunity for students to play constantly in all places.^[20]

Similar studies have been conducted on application design and development. In this regard, Kanthan and Senger investigated the effect of the application on learning pathology in students in 2011. In this study, the students’ pathology course grades increased significantly with the use of game-based application training. Moreover, students’ satisfaction, individual learning, and stress reduction were observed.^[21]

Janssen et al. discussed the effect of the application on learning anatomy and histology in students. Approximately 89% of individuals were satisfied with this new method, 93% found it challenging, and 73% reported the desire to carry on learning with this application. Finally, the study findings indicated that this method was efficacious in acquiring anatomy knowledge and attracting students.^[22]

In another study, Gudadappanavar et al. investigated the effect of a game-based application on students’ pharmacology course learning and reported students’ higher grades using the application. Furthermore, students’ feedback and interest in this group were greater, considering this method unique, active, and entertaining.^[15]

Tsopra et al. designed an application to train students on the use of antibiotics. Students considered this method attractive, practical, enjoyable, and appropriate for learning. Nearly 87% to 89% of individuals considered it inspiring, and 96% were engrossed by this game.^[18]

By designing an educational application to facilitate learning neurology, Anton Raskurazhev et al. achieved significant results by comparing scores before and after using the application. They reported significant positive results while using this method and referred to educational games as an appropriate choice for medical education; these games were promotable, cost-effective, and influential for increasing concern and motivation in medical students.^[23]

Despite the effectiveness of the application in the above studies, in the study by Jesse Courtier et al., which was conducted to compare the effectiveness of training radiology through traditional and game-based methods, the findings showed that the students in the traditional training group obtained higher scores than those in the other group. Moreover, the understanding of the information material and their recall were reported to be greater in the traditional methods group. However, no significant difference was observed in the students’ interest in radiology knowledge between the two groups.^[24]

Due to the global prevalence of these oral lesions and their impact on individuals’ quality of life, the significance of pathology knowledge for early diagnosis of these lesions, and students’ indifference to studying and learning pathology, it is necessary to utilize novel learning approaches. Therefore, considering the contradictory findings about the impact of educational applications on students’ learning and the limitations of this method in learning oral pathology in Iran and abroad, this study aimed to design and develop an application for teaching oral pathology to dental students to promote the education, diagnosis, and treatment of pathological lesions.

The present quasi-experimental study was conducted in 2022–2023 at the Dentistry Faculty of Isfahan University of Medical Sciences. An application was designed for 112 3^rd-year dental students to learn oral pathology.

The protocol was approved with the number IR.MUI.RESEARCH.REC.1401.171 by the Ethics and Research Committee of Isfahan University of Medical Sciences.

The mean age of the students was 21.8 ± 5.1 years, and their mean average score was 16.4 ± 2.1. Sixty-four students (57.1%) were male, and 48 (42.9%) were female. In total, 45 students (40.2%) had used the application.

In the present study, the average age of the participants was 21.8 years, and most of them were men, with a mean average age of 16.4 years. After designing a learning application and its voluntary implementation for the students of the 6^th semester in 2022–2023, the results of the students’ midterm examination showed that the mean score of the questions related to the application was higher for both groups of students who had used the application and those who had not. This may be related to the simplicity of the content for the midterm; however, the difference was not significant. In fact, regarding the question’s difficulty, both groups could easily identify the correct option.

The application satisfaction scores among the students who used this method were 76.8% and 74.8% in the midterm and final examinations, respectively, which was due to the innovative design of the application, the novelty of this method in education, its entertaining and challenging nature, its effectiveness in learning the lesson content, and its helpfulness in the retention of lesion tips to remember. This indicates that the application was user-friendly and that all users were relatively satisfied. In line with the present study, Arayapisit et al. investigated the use of educational games in learning about orofacial infections in Thailand in 2022, and the findings showed a significant increase in students’ evaluation scores. The students were satisfied with this method and found it to be entertaining and effective in learning, understanding concepts, clinical application of knowledge, and content review.^[25]

The mean score of questions related and unrelated to the application had an inverse relationship with students’ age. In other words, with increasing age, the mean scores of questions related and unrelated to the application decreased because older students were more occupied with their occupations or family responsibilities and consequently lacked adequate time to study or were less motivated. Notably, young people are more likely to utilize technology than older people are. Moreover, the mean score of questions related and unrelated to the application was directly related to students’ average score, indicating that pathology knowledge was more important for students who had obtained higher grades in other subjects or that the importance of the grade obtained in this subject and its effect on the average score was greater for them. Accordingly, they devoted more time to studying it or were more motivated. Regarding gender, there was no significant difference in the satisfaction score with the application between male and female students, indicating that both groups of students appreciated the application, and its feedback had no relationship with their gender.

In total, 40.2% of the students used the application. Despite encouraging the students to use the application, the acceptance level of this method by the students was not as expected, which can be attributed to the low internet speed in the country, the lack of motivation to study, especially in basic courses such as oral and maxillofacial pathology, the difficulty of pathology topics, and the large amount of information materials presented. Other reasons include the short examination preparation time, the intensive midterm and final examinations, the prevailing culture of giving importance to specialized courses other than pathology, and the lack of awareness of the importance and clinical application of this knowledge in the patient examination, diagnosis, and management of pathological lesions. Approximately 57.7% of the students who used the application were female, which was probably due to female students’ greater interest in using electronic devices, greater use of educational aids by females, greater time devoted to study, and greater effort in acquiring higher scores.

The results of the final examination showed that the mean scores for questions related and unrelated to the application were significantly greater for students who had used the application, indicating that using the application familiarized students with questions and helped them answer more questions unrelated to the application in addition to more related questions [Tables 1 and 2]. The difference in the results of the midterm examination could be due to the students’ less familiarity with the use of the application; over time, the students became completely familiar with the application and obtained better results.

In the final examination, age had an inverse relationship with the mean scores of related and unrelated questions, while the average score had a direct relationship with the scores for reasons similar to those of the midterm examination. Concerning the students’ gender, the mean satisfaction and related scores were greater for women than men; however, there was no significant difference. The importance of this subject’s scores and their effect on the overall average score were probably greater for female students; as a result, the motivation, effort, and study time allocated were greater.

In line with the present study, to facilitate the learning of neurology in residents, Raskurazhev et al. designed and developed a game-based learning application in Russia in 2021 and evaluated the effectiveness of that method through an approach that varied from that used in the present study. By comparing the results of a questionnaire with the content of neurology questions before and after using the application, the mean scores of the questionnaire after using the application were significantly greater. Moreover, similar to the present study, the results were not correlated with students’ gender.^[23]

This study showed that the mean scores for questions related and unrelated to the application were greater for application users. Eighty percent of those who had used the application for the midterm examination used it in the final examination, and 9% of new users used it in the final examination evaluation. This increase could be as a reason for previous familiarity, accessibility of the application in a more extended time and its effect on the student’s grades, allocating more examination preparation time for the final examination rather than the midterm examination, and the importance of final examination grades compared to the midterm examination from the students’ point of view.

In this regard, the findings of Tsopra et al.’s (2020) study on the use of a game in pharmacology education in France showed a significant positive correlation between students’ scores on the application and their final examination grades. The students who had used the application obtained a higher grade on their final examination. In addition, the students believed that using the application was an entertaining method for reviewing the educational content and was effective in their understanding.^[18]

Contrary to the present study, Courtier et al. designed and developed a game for the radiology course in 2016. In contrast, they put the students in two groups: traditional education and education through games. In the final examination, the results showed that the traditional education group obtained higher grades than did the education through the games group. According to the satisfaction questionnaire, education through games was entertaining for students, similar to the findings of the present study; however, in contrast, it did not greatly increase students’ interest.^[24] The difference between the results of the above study and the present study was due to the use of dissimilar evaluation methods. In the present study, the combined teaching method, adding a game to traditional teaching methods, was used; however, in the above study, education was provided through games and traditional methods separately in the two groups. Therefore, the combined teaching method had a more significant effect on students’ learning and understanding of the material.

In general, the evaluation of the satisfaction questionnaire separately in both the midterm and final examinations showed that the installation and login to the application, as well as the successful storage of information, were highly satisfactory for most users, indicating the application’s faultless design in these areas.

Furthermore, in both examinations, the content of the application questions (including four-choice, true–false, and short-answer questions and cases), which were designed under the supervision of oral pathology professors, was proportionate to the lesson plan content. The quality of the uploaded application images was acceptable according to most users. Moreover, the design of the application was appreciated by the majority of users. The impact of the application in acquiring pathology knowledge on both examinations was high for most students. Interestingly, the impact of the application in increasing students’ interest in this knowledge and learning lesson plan content was moderate to high for most individuals on both examinations. In line with the present study, a study conducted by Felszeghy et al. in 2019; in Finland, on using a game-based platform to improve students’ performance and encourage them to participate in histology education showed that this method was successful and that its users were highly satisfied. This method increased students’ motivation to learn, and the gamification approach increased students’ interest.^[26]

In this study, most users in both examinations found this method entertaining and challenging. Gudadappanavar et al., who investigated the effectiveness of game application on the learning of pharmacology in students in 2021, reported that students’ feedback and interest in the application group were greater in the present study, and they considered this method amusing and dynamic.^[15] Similar to the study by Tsopra et al., who reported this method to be effective in reviewing educational content and understanding students, the effectiveness of the application in reviewing lesions before the examination in this study was moderate to high.^[18] In line with this study, Raskurazhev et al. reported that most students found the application satisfactory and recommended it to others.^[23] Despite the students’ high satisfaction with the design of the application and its content questions, its entertaining nature, and its better impact on learning the course content, this method seems to be less effective in reducing the students’ stress in the examination session and increasing their self-confidence when facing actual clinical cases [Table 3]. The reasons for this could be the challenging nature of pathology, the large quantity of examination content, the short examination preparation period, inadequate study during the semester, the theoretical nature of the content, and perhaps, the difficulty of the questions designed for the examination.

The results showed that new educational methods, such as applications, improved students’ knowledge and understanding of pathology. Fortunately, the users’ satisfaction and interest confirmed the success of the present application. Therefore, this method can be used to increase students’ learning of extensive medical science.