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Student endodontic access cavity preparation: Performance versus perception
0099-2399/85/1104-0188/$02.00/0 JOURNALOF ENDOOONTICS Copyright 9 1985 by The American Association of Endodontists
Printed in U.S.A. VOL. 11, NO. 4, APRIL 1985
Student Endodontic Access Cavity Preparation: Performance Versus Perception Preparacion de la Cavidad de Acceso Endodontico por Estudiantes: Performance Versus Percepcion Joseph C. Kehoe, BS, DDS, MS
work are key elements in evaluating student performance by faculty. The traditional endodontic curriculum of "tell, show, and do" has been modified at Florida with a self-paced, competency-based modular curriculum. Endodontic instructional material describes the type of activities to be performed and criteria for acceptable performance (2). Access preparation is incorporated into the preclinical laboratory with sufficient time to allow the student to achieve competency in the technical procedures prior to any clinical experience. The objectives of adequate access preparation are complete debridement of the contents of the pulp chamber, location of each canal orifice, and straight line access to the apical foramen. Repetition of the access procedures is required until the objectives are attained. Although the preclinical module is self-paced, practical time requirements are necessary to bring about an orderly completion. The endodontic curriculum consists of four modular units of instruction. The didactic modules cover pulp and periapical pathology, diagnosis and treatment of reversibly involved pulps of primary and permanent teeth, and the diagnosis, selection, and treatment of teeth whose pulps are irreversibly involved. The preclinical module teaches basic endodontic procedures on extracted human teeth. The clinical module includes the treatment of four anterior/bicuspid teeth and four molar teeth as a minimum, plus the interdisciplinary aspects of endodontics. Upon completion of all preclinical and clinical modules, the senior students complete a comprehensive clinic posttest also known as the "mockboard." Demonstration of endodontic access preparation is one requirement of this mockboard. The purpose of this article is to describe the student self-assessment session as an educational process and to determine whether the students can benefit from their mistakes when confronted with their board access preparations. If the student's assessment comparison
A voluntary critique of endodontic access preparations was offered to all graduating seniors upon completion of the terminal endodontic clinical posttest. The purpose of the critique session was to evaluate a student's self-assessment skills and to determine whether any benefits occur from the review. The students were not informed of this purpose. The students that participated scored higher on the state board examination than those that did not participate in the self-critique session. Una critica voluntaria sobre la preparacion del acceso endodontico se le ofrecio a todos los alumnos avanzados que completaban la prueba final de la clinica endod6ntica. El propbsito de esta sesion critica fue la autoevaluacion de los estudiantes sobre sus habilidades y determinar si se obtenian beneficios de esta revision. Los estudiantes no fueron informados de este proposito. Los que participaron obtuvieron puntajes m~,s altos en los examenes estatales de certificacion comparados con aquellos que no participaron en las sesiones de autocritica.
To provide quality assurance to their patients is the moral and legal responsibility of each practitioner, dental educator, and dental student (1). Clinicians of predoctoral endodontic curriculum understand the value of a student being able to properly critique completed clinical procedures. Self-assessment of one's clinical abilities and rendered treatment is not easily taught and is difficult to measure. Self-evaluation by the student can be enhanced by a faculty that develops performance criteria based,on reasonable, time-tested standards. A clear statement of what is acceptable/unacceptable provides a beginning for the student to develop self-assessment skills. The quality of work, the quantity of ~Nork, and the time interval to complete the 188
Vol. 11, No. 4, April 1985
agrees with the actual performance, then the student's ability to assess his endodontic access skills is enhanced and gives additional clinical relevance to this educational process.
Access Cavity Preparation
189
examination are included to determine if a relationship exists between the student self-evaluation session and state board success in endodontics. RESULTS
MATERIALS AND METHODS
The senior class of 57 students was selected for observation, comparison, and evaluation. Each student's grade for the endodontic access portion of the preclinical module was recorded. The mockboard grades were based on the average of three faculty's scoring while the state board grades were based on the average of three dental examiners' scoring. Both were graded on a 0 to 5 scale with a 5 outstanding, 0 failing, and an overall average of 3 required for passing. Criteria used to evaluate each access included; correct outline form, removal of the roof of the pulp chamber and pulp horns, straight line access to all canals, presence of remaining adequate dentin, and the absence of gouging on the floor or walls. The 57 seniors were grouped into three units because of varying graduation times. Group 1 was comprised of 13 December graduates. Group 2 was comprised of 40 students that graduated in June or 4 calendar yr. Group 3 was comprised of four students who completed all modules in 41/2 calendar yr. Members of the University of Florida faculty served as the mockboard examiners and were selected at random from a list of volunteers submitted to the mockboard faculty coordinator. Two general dentists and one endodontist were selected to evaluate the restorative and endodontic access portion of the first group. One general dentist and two endodontists were selected to evaluate the endodontic access portion of the second and third group. The grades from preclinical experience, mockboard examination, student self-evaluation, and state board examination were compiled and analyzed. Approximately 2 wk after the mockboard examinations and before the state board examinations, a critique schedule was announced to all 57 seniors via individual memorandum. The purpose was to allow each student to examine his/her endodontic access models, consisting of a lower central incisor and a lower first molar from the same quadrant, with an evaluator. Attendance was encouraged but not required. The students were given their access models, radiographs, and blank mock-board grading forms which included an explanation of the 0 to 5 grading system. They were directed to evaluate their access preparations using the same criteria as the mockboard examiners and to enter the grades on the appropriate cards. Group 2 was further divided into subgroup A, comprised of 19 students that attended the critique, and subgroup B of 21 students that did not attend the critique. The students' results on the endodontic portion of the state board
Table 1 presents a one-way analyses of variance comparing early graduates (group 1) to the normal June graduates (group 2) and extended graduates (group 3) relative to how they performed on state board examinations. No statistically significant differences between the groups was found. Group 2 performance (Tables 2 and 3) on the state board was divided into subgroup A (critique) and subgroup B (no critique). These data showed that subgroup A performed significantly better (p = 0.018391) on the state board examination than did subgroup B. It was further observed that all groups participating in the self-evaluation of their mockboard access preparations showed improvement on state board scores as opposed to subgroup B that demonstrated a decline in state board scores. DISCUSSION
The hypothesis that students' ability to identify and improve from reviewing their mockboard mistakes can be supported by this study. According to this analysis, review and self-assessment of mockboard access preparations prior to state board examinations contributed TABLE 1. Data from the three groups investigated No. of Preclinical Students Grade*
Group 1 2 3
13 40 4
4.28 4.20 3.91
Mock Student State Board SelfBoard Gradet evaluation:~ Grade1" 3.50 3.56 3.37
3.61 3.41 3.50
3.77 3.87 4.04
9 Average of three access grades on a 0 to 4 scale converted to a 0 to 5 scale for companson. t Average of two access grades per examiner on a O to 5 scale. ~; Average of two access grades.
TABLE 2. Data from group 2 Subgroup Letter A B
Mock Student State No. of Preclinical Board SelfBoard Students Grade* Grader evaluation:~ Grader 19 21
4.24 4.16
3.37 3.73
3.41
4.06 3.63
9 Average of three access grades on a O to 4 scale converted to a 0 to 5 scale for comparison. t Average of two access grades par examiner on a 0 to 5 scale. ~: Average of two access grades.
TABLE 3. Evaluation of subgroup participation in the mock board critique and state board results Comparison of Subgroups Significance A
B
4.06* _+ 0.06
3.63 _+ 0.66
* Mean _+ SD.
p = 0.018391
190
Kehoe
to a higher level of performance for all students in groups 1 and 3 and 19 students from group 2, subgroup A. There was no statistical difference in-the computed average of the combined didactic/clinical endodontic standing of the students from subgroup A when compared with those of subgroup B. The generally high preclinical grades reflected a period when mastery of technical procedures was attained by repetition leading to this result. Specific performance criteria developed by the faculty probably aided the student with self-assessment of access preparations prior to submission for grading. Interpretation among examiners for the mockboard was closely observed after the same technical performance criteria plus clinical examples were provided and explained in detail. Clarification of these criteria or checkpoints is essential to promote agreement among evaluators (3). Although examiners came from three separate departments, evaluation consistency was acceptable with little variation. An analysis of the results of the mockboard access evaluation for groups 1 and 2 when compared with the state board results demonstrate considerable improvement. Group 3, although a small sample size, showed a similar result. For the early graduates, self-evaluation was slightly higher than that of the mockboard examiners where the reverse was true of group 2, the normal or 4-yr graduate. All students in groups 1 and 3 participated in the self-evaluation critique. In group 2, 19 of 40 participated in the self-evaluation. While all of the students that availed themselves of the additional opportunity to critique the mockboard results increased their state board scores, the significant difference between the subgroups of group 2 was a gratifying finding. These results lend support for developing selfevaluation skills on the part of students. Self-evaluation is a necessarv skill of a dentist in private practice. The
Journal of Endodontics
more we include self-evaluation in the undergraduate curriculum, the more likely are we to have students and graduates that are discerning judges of their clinical work. SUMMARY
This self-paced approach to endodontic teaching has allowed the student to develop and improve his/her endodontic access skills over an 18- to 24-month period. Adding the voluntary critique opportunity has allowed the faculty to observe the students' ability to assess mock-board results. The critique encompasses dental anatomy, pulp morphology, and the objectives of access preparation that leads to preclinical and clinical competency. Reinforcement of access standards is a successful method of improving the student's ability to recognize errors, concentrate on the ideal, and improve technique. The results of this statistical review were instrumental in the decision to incorporate the self-evaluation into the endodontic curriculum. I wish to thank Arthur D. King, MS, PhD, Department of Dental Education, University of Florida College of Dentistry, for his advice and guidance in the preparation of this article. Dr. Kehoe is assistant professor, College of Dentistry, University of Florida, Gainesville, FL
References 1. American Dental Association, Emphasis. Quality assurance: five experts examine the issues. J Am Dent Assoc 1982;104:608-17. 2. King AD, Mackenzie RS, Bass RK, Balanoff N. Dental education: a review of the rationale of the University of Florida's modular curriculum. FL Dent J 1982;53:10-43. 3. Mackenzie RS, Antonson DE, Weldy PL, Welsch BB, Simpson WJ. Analysis of disagreement in the evaluation of clinical products. J Dent Educ 1982;46:284-9.
Printed in U.S.A. VOL. 11, NO. 4, APRIL 1985
Student Endodontic Access Cavity Preparation: Performance Versus Perception Preparacion de la Cavidad de Acceso Endodontico por Estudiantes: Performance Versus Percepcion Joseph C. Kehoe, BS, DDS, MS
work are key elements in evaluating student performance by faculty. The traditional endodontic curriculum of "tell, show, and do" has been modified at Florida with a self-paced, competency-based modular curriculum. Endodontic instructional material describes the type of activities to be performed and criteria for acceptable performance (2). Access preparation is incorporated into the preclinical laboratory with sufficient time to allow the student to achieve competency in the technical procedures prior to any clinical experience. The objectives of adequate access preparation are complete debridement of the contents of the pulp chamber, location of each canal orifice, and straight line access to the apical foramen. Repetition of the access procedures is required until the objectives are attained. Although the preclinical module is self-paced, practical time requirements are necessary to bring about an orderly completion. The endodontic curriculum consists of four modular units of instruction. The didactic modules cover pulp and periapical pathology, diagnosis and treatment of reversibly involved pulps of primary and permanent teeth, and the diagnosis, selection, and treatment of teeth whose pulps are irreversibly involved. The preclinical module teaches basic endodontic procedures on extracted human teeth. The clinical module includes the treatment of four anterior/bicuspid teeth and four molar teeth as a minimum, plus the interdisciplinary aspects of endodontics. Upon completion of all preclinical and clinical modules, the senior students complete a comprehensive clinic posttest also known as the "mockboard." Demonstration of endodontic access preparation is one requirement of this mockboard. The purpose of this article is to describe the student self-assessment session as an educational process and to determine whether the students can benefit from their mistakes when confronted with their board access preparations. If the student's assessment comparison
A voluntary critique of endodontic access preparations was offered to all graduating seniors upon completion of the terminal endodontic clinical posttest. The purpose of the critique session was to evaluate a student's self-assessment skills and to determine whether any benefits occur from the review. The students were not informed of this purpose. The students that participated scored higher on the state board examination than those that did not participate in the self-critique session. Una critica voluntaria sobre la preparacion del acceso endodontico se le ofrecio a todos los alumnos avanzados que completaban la prueba final de la clinica endod6ntica. El propbsito de esta sesion critica fue la autoevaluacion de los estudiantes sobre sus habilidades y determinar si se obtenian beneficios de esta revision. Los estudiantes no fueron informados de este proposito. Los que participaron obtuvieron puntajes m~,s altos en los examenes estatales de certificacion comparados con aquellos que no participaron en las sesiones de autocritica.
To provide quality assurance to their patients is the moral and legal responsibility of each practitioner, dental educator, and dental student (1). Clinicians of predoctoral endodontic curriculum understand the value of a student being able to properly critique completed clinical procedures. Self-assessment of one's clinical abilities and rendered treatment is not easily taught and is difficult to measure. Self-evaluation by the student can be enhanced by a faculty that develops performance criteria based,on reasonable, time-tested standards. A clear statement of what is acceptable/unacceptable provides a beginning for the student to develop self-assessment skills. The quality of work, the quantity of ~Nork, and the time interval to complete the 188
Vol. 11, No. 4, April 1985
agrees with the actual performance, then the student's ability to assess his endodontic access skills is enhanced and gives additional clinical relevance to this educational process.
Access Cavity Preparation
189
examination are included to determine if a relationship exists between the student self-evaluation session and state board success in endodontics. RESULTS
MATERIALS AND METHODS
The senior class of 57 students was selected for observation, comparison, and evaluation. Each student's grade for the endodontic access portion of the preclinical module was recorded. The mockboard grades were based on the average of three faculty's scoring while the state board grades were based on the average of three dental examiners' scoring. Both were graded on a 0 to 5 scale with a 5 outstanding, 0 failing, and an overall average of 3 required for passing. Criteria used to evaluate each access included; correct outline form, removal of the roof of the pulp chamber and pulp horns, straight line access to all canals, presence of remaining adequate dentin, and the absence of gouging on the floor or walls. The 57 seniors were grouped into three units because of varying graduation times. Group 1 was comprised of 13 December graduates. Group 2 was comprised of 40 students that graduated in June or 4 calendar yr. Group 3 was comprised of four students who completed all modules in 41/2 calendar yr. Members of the University of Florida faculty served as the mockboard examiners and were selected at random from a list of volunteers submitted to the mockboard faculty coordinator. Two general dentists and one endodontist were selected to evaluate the restorative and endodontic access portion of the first group. One general dentist and two endodontists were selected to evaluate the endodontic access portion of the second and third group. The grades from preclinical experience, mockboard examination, student self-evaluation, and state board examination were compiled and analyzed. Approximately 2 wk after the mockboard examinations and before the state board examinations, a critique schedule was announced to all 57 seniors via individual memorandum. The purpose was to allow each student to examine his/her endodontic access models, consisting of a lower central incisor and a lower first molar from the same quadrant, with an evaluator. Attendance was encouraged but not required. The students were given their access models, radiographs, and blank mock-board grading forms which included an explanation of the 0 to 5 grading system. They were directed to evaluate their access preparations using the same criteria as the mockboard examiners and to enter the grades on the appropriate cards. Group 2 was further divided into subgroup A, comprised of 19 students that attended the critique, and subgroup B of 21 students that did not attend the critique. The students' results on the endodontic portion of the state board
Table 1 presents a one-way analyses of variance comparing early graduates (group 1) to the normal June graduates (group 2) and extended graduates (group 3) relative to how they performed on state board examinations. No statistically significant differences between the groups was found. Group 2 performance (Tables 2 and 3) on the state board was divided into subgroup A (critique) and subgroup B (no critique). These data showed that subgroup A performed significantly better (p = 0.018391) on the state board examination than did subgroup B. It was further observed that all groups participating in the self-evaluation of their mockboard access preparations showed improvement on state board scores as opposed to subgroup B that demonstrated a decline in state board scores. DISCUSSION
The hypothesis that students' ability to identify and improve from reviewing their mockboard mistakes can be supported by this study. According to this analysis, review and self-assessment of mockboard access preparations prior to state board examinations contributed TABLE 1. Data from the three groups investigated No. of Preclinical Students Grade*
Group 1 2 3
13 40 4
4.28 4.20 3.91
Mock Student State Board SelfBoard Gradet evaluation:~ Grade1" 3.50 3.56 3.37
3.61 3.41 3.50
3.77 3.87 4.04
9 Average of three access grades on a 0 to 4 scale converted to a 0 to 5 scale for companson. t Average of two access grades per examiner on a O to 5 scale. ~; Average of two access grades.
TABLE 2. Data from group 2 Subgroup Letter A B
Mock Student State No. of Preclinical Board SelfBoard Students Grade* Grader evaluation:~ Grader 19 21
4.24 4.16
3.37 3.73
3.41
4.06 3.63
9 Average of three access grades on a O to 4 scale converted to a 0 to 5 scale for comparison. t Average of two access grades par examiner on a 0 to 5 scale. ~: Average of two access grades.
TABLE 3. Evaluation of subgroup participation in the mock board critique and state board results Comparison of Subgroups Significance A
B
4.06* _+ 0.06
3.63 _+ 0.66
* Mean _+ SD.
p = 0.018391
190
Kehoe
to a higher level of performance for all students in groups 1 and 3 and 19 students from group 2, subgroup A. There was no statistical difference in-the computed average of the combined didactic/clinical endodontic standing of the students from subgroup A when compared with those of subgroup B. The generally high preclinical grades reflected a period when mastery of technical procedures was attained by repetition leading to this result. Specific performance criteria developed by the faculty probably aided the student with self-assessment of access preparations prior to submission for grading. Interpretation among examiners for the mockboard was closely observed after the same technical performance criteria plus clinical examples were provided and explained in detail. Clarification of these criteria or checkpoints is essential to promote agreement among evaluators (3). Although examiners came from three separate departments, evaluation consistency was acceptable with little variation. An analysis of the results of the mockboard access evaluation for groups 1 and 2 when compared with the state board results demonstrate considerable improvement. Group 3, although a small sample size, showed a similar result. For the early graduates, self-evaluation was slightly higher than that of the mockboard examiners where the reverse was true of group 2, the normal or 4-yr graduate. All students in groups 1 and 3 participated in the self-evaluation critique. In group 2, 19 of 40 participated in the self-evaluation. While all of the students that availed themselves of the additional opportunity to critique the mockboard results increased their state board scores, the significant difference between the subgroups of group 2 was a gratifying finding. These results lend support for developing selfevaluation skills on the part of students. Self-evaluation is a necessarv skill of a dentist in private practice. The
Journal of Endodontics
more we include self-evaluation in the undergraduate curriculum, the more likely are we to have students and graduates that are discerning judges of their clinical work. SUMMARY
This self-paced approach to endodontic teaching has allowed the student to develop and improve his/her endodontic access skills over an 18- to 24-month period. Adding the voluntary critique opportunity has allowed the faculty to observe the students' ability to assess mock-board results. The critique encompasses dental anatomy, pulp morphology, and the objectives of access preparation that leads to preclinical and clinical competency. Reinforcement of access standards is a successful method of improving the student's ability to recognize errors, concentrate on the ideal, and improve technique. The results of this statistical review were instrumental in the decision to incorporate the self-evaluation into the endodontic curriculum. I wish to thank Arthur D. King, MS, PhD, Department of Dental Education, University of Florida College of Dentistry, for his advice and guidance in the preparation of this article. Dr. Kehoe is assistant professor, College of Dentistry, University of Florida, Gainesville, FL
References 1. American Dental Association, Emphasis. Quality assurance: five experts examine the issues. J Am Dent Assoc 1982;104:608-17. 2. King AD, Mackenzie RS, Bass RK, Balanoff N. Dental education: a review of the rationale of the University of Florida's modular curriculum. FL Dent J 1982;53:10-43. 3. Mackenzie RS, Antonson DE, Weldy PL, Welsch BB, Simpson WJ. Analysis of disagreement in the evaluation of clinical products. J Dent Educ 1982;46:284-9.