J Dent Educ. 68(8): 829-833 2004
© 2004 American Dental Education Association
Critical Issues in Dental Education |
Improving Performance on the Endodontic Section of the Florida Dental Licensure Examination
Carol M. Stewart, D.D.S., M.S.;
Frank J. Vertucci, D.M.D.;
Robert E. Bates, D.D.S., M.S.
Key words: dental licensure examinations, endodontic criteria, mock board examination
Submitted for publication 02/17/04;
accepted 06/02/04
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Abstract
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In an attempt to improve performance of University of Florida College of Dentistry (UFCD) graduates on the endodontic section of the Florida Dental Licensure Examination, a retrospective analysis was conducted for classes graduating between 1996 and 2003 to assess potential relationships between passing and failing performance and three factors with potential impact on "first attempt" pass rates. The three factors were clinical endodontic experience, performance on the senior mock board examination, and dialogue with representatives of the licensure examination, which resulted in modification of the endodontic section of the licensure exam. Using ANOVA, we found no differences in performance on the endodontic section of the senior mock board exam between graduates who passed the endodontic section of the dental licensure exam and those who failed this section. Furthermore, no differences were found in the mean number of clinical endodontic experiences (number of teeth treated) between graduates who passed the endodontic section of the licensure exam and those who failed. However, in 2003 following dialogue between representatives of the Florida Board of Dentistry and endodontic faculty from the two dental schools in Florida, a significant difference in senior mock board endodontic scores (p>0.05) and a significant difference in performance on the endodontic section of the licensure exam scores (p>0.005) was observed for the 2003 graduates when compared to the 2002 graduates. The mean mock board scores and the mean state board endodontic section scores were higher for the 2003 graduates. In addition, the UFCD failure rate on the endodontic section of the state board exam dropped from 34 percent in 2002 to 6 percent in 2003. The primary factors believed responsible for these improvements were a direct result of dialogue between dental school faculty and state board representatives. They include a greater appreciation by the UFCD faculty for the performance criteria used by the Board of Dentistry to evaluate procedures and a change by the board in the tooth selection criteria for the endodontic experience. The options in tooth-type used in the board exams increased from a two-rooted maxillary premolar to any anterior or premolar tooth. In conclusion, this report supports the positive benefits from ongoing discussions between dental school faculty and representatives of the state licensure board.
A national concern for U.S. dental schools is the performance of graduates on state/regional licensure exams as this measure is a common benchmark for measuring effectiveness of clinical programs. Following graduation, approximately 90 percent of University of Florida College of Dentistry (UFCD) graduates attempt the state dental licensure examination. Tracking student performance and seeking strategies to improve performance are ongoing endeavors. An annual review is conducted at UFCD to assess graduates’ performance on the most recent state board examination and to compare that with previous years’ performance. Such a review in 2001 suggested an increase in failures from previous years for the endodontic section of the exam. Results from the June 2000 licensure exam showed that 27 percent of UFCD graduates who took the licensure exam failed the endodontic section. Results from the 2001 exam showed that 34 percent of the UFCD graduates who took the exam failed the endodontic section, an increase of 25 percent. Discussions ensued to identify key factors related to performance on the endodontic section with the anticipated outcome of improving pass rates. Following significant improvement in the UFCD performance on the 2003 endodontic section of the dental licensure exam (failure rate of 6 percent), a review was conducted to identify factors influencing that outcome. To facilitate the process, a retrospective analysis was conducted on UFCD graduates of classes 1996–2003 looking for relationship factors that could impact performance. This article will discuss three factors relating to endodontics that are traditionally thought to have a profound effect on training and performance: clinical endodontic experience and patient supply, senior mock board performance, and the effect of dialogue and effective communication with representatives of the licensure board.
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Clinical Experiences
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As most educators would agree, adequacy of clinical endodontic experiences is essential to certify clinical competence and to ensure the acquisition of judgment and skills for successful performance on state/regional licensure examinations. A prime factor in attaining competency is the number of patients in the predoctoral student’s patient pool who have endodontic needs. Patient supply has been an important issue for many years. Meskin1,2 reported that there was an adequate supply of patients with endodontic needs nationwide in 1969 and 1985 to meet the educational needs of dental students. Results of a 1985 mail questionnaire2 received from fifty-nine United States and ten Canadian dental schools, while indicating a potentially serious problem in obtaining and maintaining dental teaching patients, noted that a majority of dental schools had an adequate supply of all types of endodontic patients. However, a recent article by Littlefield et al. indicates that patient supply is a concern for many dental schools. This educational need might be met, in part, by multimedia patient simulation for teaching and assessing endodontic diagnostic skills.3
The University of Florida College of Dentistry noted a gradual decline in the number of endodontic treatment procedures completed per predoctoral dental student over the past seven years. As shown in Table 1
, the average number of clinical endodontic experiences per dental student for all case types declined from 7.0 teeth in 1996 to 5.4 teeth in 2002. Some UFCD faculty postulated the decrease in predoctoral endodontic experiences was due to inappropriate referral of predoctoral cases to the graduate program. Criteria for referral of a patient to the graduate program due to case complexity include the following: previous endodontic therapy requiring retreatment; canal curvatures greater than 30 degrees; radiographic evidence of significant canal calcification; and the presence of serious infection, such as a cellulitis. A review of all therapy performed by four endodontic graduate students who completed their course of study in June 2001 indicated inappropriate referrals accounted for less than 1 percent of their total case load. The authors interpreted these findings to indicate that the graduate endodontic program had a very mild negative impact on the availability of predoctoral cases.4
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Table 1. Average number of endodontic experiences (teeth treated) per predoctoral dental student and failure rate for endodontic section of the state board exam
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A second reason for the decline in patient availability for endodontic treatment is patient financial resources. Anecdotal comments from UFCD Treatment Planning faculty and faculty in the Oral Surgery Clinic provide evidence that economic factors play a significant role in determining whether a tooth is to be retained or extracted. While UFCD predoctoral fees are 50 percent or less than the local private practitioner’s fees, financial constraints often result in patient declination of endodontic procedures in favor of less costly, alternative treatments.
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Senior Mock Board Performance
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The second factor that might affect performance on the state licensure exam is the performance on the senior mock board exam. As reported by Jessee,5 most dental schools appreciate the potential of a mock board examination to help prepare their graduates to pass licensure exams. At UFCD, the mock board course of instruction is an important educational experience for senior dental students. Successful completion of this course and the mock board competency exam is a requirement for graduation. The endodontic section of the mock board exam and the state licensure exam require the same procedures. The endodontic mock board exercise from 1996 to 2002 consisted of root canal therapy on an extracted two-rooted maxillary premolar. Grading criteria for the endodontic sections of the mock board and state licensure exam include an assessment of access preparation, canal identification, shaping and cleaning of canals, and proper obturation with gutta percha. Pre- and post-treatment radiographs plus the mounted treated tooth were required for submission. Evaluation is one composite score 0–5, with "0" meaning a failing score and "5" being outstanding performance, with 
3 required for passing. The endodontic section comprises 10 percent of the entire examination.
The mock board exam serves to subject students to the same performance criteria, time management issues, and stressors associated with the licensure exam. In the case of the endodontic mock board exam, between 1996 and 2002, significant student stress was associated with finding adequate extracted right and left two-rooted maxillary first pre-molar teeth that had no caries or restorations and which had a normal pulp cavity.
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Dialogue with State Board Representatives
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The third factor for improving performance on the mock board or licensure examination is an understanding of performance expectations gained through dialogue with faculty and licensure exam representatives. Dialogue between UFCD faculty, Nova Southeastern University College of Dental Medicine faculty, and the Florida Board of Dentistry regarding endodontic procedures began in the winter of 2001. Initially, the board provided the two dental schools with sample dentoform work from previous exams for faculty review. All identifiers were removed from the models. This allowed UFCD to more clearly understand the state board criteria for the entire exam and then incorporate those concepts into the senior mock board course. Continuing in the spirit of dialogue and communication, in December 2002, two faculty from UFCD, two faculty from Nova, and three representatives from the Florida State Board of Dentistry met and reviewed a variety of issues related to the state licensure exam. The group shared thoughts related to contemporary techniques and acceptable outcomes. Subsequently, the board modified the endodontic procedure. Effective with the June 2003 exam, candidates could select any incisor, cuspid, or premolar tooth for the endodontic procedure. This modification allowed students to expand their opportunities to locate ideal teeth and provided additional opportunities for practice, remediation, and enhanced preparation for the endodontic section of the senior mock board and state licensure exam.
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Methods
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Senior mock board exam performance and clinical productivity data were collected for the past eight dental classes that graduated from UFCD (1996–2003). This data was then combined with state dental licensure exam results supplied by the Florida Department of Health, Division of Medical Quality Assurance, with the written permission of the UFCD graduates taking the licensure examination. Only students with complete data sets consisting of mock board results, clinical productivity data, and state licensure exam scores were included in the analyses. In all cases, once the data were collated into a single spreadsheet, individual identifiers were removed to ensure anonymity. The University of Florida Institutional Review Board granted approval for this study.
One-way analysis of variance (ANOVA) was used to compare the mean differences of the endodontic mock board procedure and the number of junior and senior year clinical root canal procedures. The scores from the endodontic section of the state licensure exam were divided into two groups: those who passed the endodontic portion of the state licensure exam (score 3.0) and those who failed the endodontic portion (score <3.0). The mock board endodontic section scores of these two groups were then compared, as were the number of endodontic procedures performed by the two groups. In each case the null hypothesis (H0) was that the means of the two groups were equal (m1 = m2), thus indicating no significant difference between the groups. The alternate hypothesis (H1) was that the means were unequal (m1 
m2) and that there are differences between groups. The calculated P value was then used to determine if the difference between groups was statistically significant. Because the endodontic portion of the state licensure exam and mock board exam changed for the 2003 graduates, two study subgroups were used. The first group included 427 graduates from 1996 to 2002. ANOVA was used to assess differences between those who passed the endodontic section of the state licensure exam and those who failed this portion of the exam for two measures: 1) mean scores on the senior mock board endodontic exam and 2) mean numbers of teeth endodontically treated during the junior and senior years. These findings are found in Table 2. The second ANOVA examined differences between the 2002 and 2003 graduates for endodontic performance on both the mock board and the state licensure examination. These results are found in Table 3.
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Table 2. Mock board endodontic performance and clinical productivity in those who passed the endodontic section of the state board exam vs. those who failed that section
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Table 3. Class of 2002 vs. Class of 2003 for mean mock board endodontic performance and state board endodontic performance
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Results
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An examination of Table 2
shows that no significant difference was detected between the mean mock endodontic scores for those who passed the endodontic section of the state board exam and those who failed that section. The mean mock board endodontic score for the 299 students who passed the state licensure exam was 2.51 (S.D. 1.1), and the mean mock board score for the 128 students who failed the endodontic section of the state board exam was 2.69 (S.D. 1.06). Also, no significant difference was found for student clinical productivity between those who passed the endodontic section of the state board exam and those who failed that section. The mean number of teeth treated for the group who passed the endodontic section of the state board exam was 6.18 (S.D. 1.67). For those who failed the endodontic section, the mean number of teeth treated was 6.25 (S.D. 1.33). The third factor contributing to the outcome of improved state board performance was the dialogue between UFCD faculty and the Florida Board of Dentistry representatives, which began in the winter of 2001.
To assess performance differences resulting from the modification of the 2003 state board exam, ANOVA was conducted for the graduating classes of 2002 and 2003, regarding differences in senior mock board endodontic performance and the state licensure exam performance. As indicated in Table 3, there was a significant difference (p<0.05) between the class of 2002 and the class of 2003 in the UFCD mean mock board endodontic scores. Additionally, there was a significant difference (p<0.005) in the state licensure exam mean endodontic scores between these two classes. The mean scores for the class of 2003 were higher on both exams than the class of 2002.
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Discussion and Conclusions
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Maintaining an appropriate and adequate patient pool for predoctoral dental students is an important concern for UFCD, as it is probably for most dental schools since students require a variable range of experiences to demonstrate competency. However, due to the overall economic status of the patients seeking care in the predoctoral dental clinics at UFCD, it has become increasingly difficult to provide adequate numbers of clinical experiences in endodontic therapy. The use of state-allocated dollars for underserved patients is being applied to selected endodontic and prosthodontic treatments for those who would otherwise not receive appropriate care. The impact of reducing fees is being investigated as well. Another option being evaluated to enhance student endodontic experience is expanding the patient pool to include therapy performed at off-site clinics where student performance is evaluated by UFCD endodontic faculty or supervising faculty calibrated by UFCD endodontists.
In addition to a patient supply, many dental faculty considered numbers of clinical procedures completed plus mock board experiences to be important components in preparing dental students to successfully complete state and/or regional licensure examinations. However, studies by Jessee5 and Ranney et al.6 failed to find significant relationships between state board pass/fail rates for clinical procedures and the numbers of clinical procedures completed by students. This was also found to be true at UFCD, as there was no significant difference in the number of clinical endodontic procedures performed by groups of students who passed or failed the endodontic portion of the state board examination. Also, there were no significant differences in mock board endodontic scores between groups who passed and those who failed the endodontic section on the state licensure examination for graduates from 1996 to 2002. As noted in Table 1, the percentage of UFCD graduates who took the state licensure exam and failed the endodontic section in 2003 dropped to 6 percent. The mean number of teeth treated per student also increased from 5.4 in 2002 to 5.9 in 2003. The sixty-five graduates who passed the endodontic section of the 2003 licensure exam averaged 5.89 procedures as students. The forty-four graduates who passed the endodontic portion of the 2002 licensure exam averaged 5.52 procedures as students. Using ANOVA, a statistically significant difference was not detected (p=0.071).
What has been identified as significant is the apparent effect of dialogue between UFCD and Nova faculty and the Florida Board of Dentistry representatives. The UFCD mock board criteria were modified to closely follow state board licensure exam criteria. The state board accepted the dental schools’ suggestion of increasing the types of teeth that could be used for the examination. This information was immediately applied to the UFCD mock board exam. The result of these changes was a significant improvement in the mock board results of 2003 over 2002, as well as a significant improvement in the state board endodontic scores for 2003 over 2002. Data is not available from the Florida Board of Dentistry to learn what percent of UFCD candidates selected single rooted teeth for the exam. Based on anecdotal comments from students, most selected single-canal incisors, cuspids, or premolars for the endodontic procedure in lieu of double-rooted premolars.
This study seems to underscore the importance of maintaining a positive and ongoing dialogue with the state/regional licensure exam representatives to assist faculty in preparing students for these critical licensure examinations.
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Footnotes
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Dr. Stewart is Associate Professor and Director, Division of Oral Diagnostic Sciences, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences; Dr. Vertucci is Professor and Chair, Department of Endodontics; and Dr. Bates is Associate Professor and Senior Associate Dean for Clinics and Operations, Department of Prosthodontics—all at the University of Florida College of Dentistry. Direct correspondence and requests for reprints to Dr. Carol M. Stewart, Associate Professor and Director, Division of Oral Diagnostic Sciences, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, P.O. Box 100414, University of Florida College of Dentistry, Gainesville, FL 32610-0414; 352-392-2505 phone; 352-392-2507 fax; cstewart{at}dental.ufl.edu.
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REFERENCES
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- Meskin LH. Current and future problems in obtaining teaching patients. J Dent Educ 1969;33(1):112–8.[Medline]
- Meskin LH, Entwistle B. Current and future projections of dental school patient availability. J Dent Educ 1985;49(8):565–9.[Abstract]
- Littlefield JH, Demps EL, Keiser K, Chatterjee L, Yuan CH, Hargreaves KM. A multimedia patient simulation for teaching and assessing endodontic diagnosis. J Dent Educ 2003;67(6):669–77.[Abstract]
- Stewart CM, Vertucci FJ, Bates RE. Impact of a graduate endodontic program on predoctoral clinical experiences. J Dent Educ 2002;66(2):324.
- Jessee SA. An evaluation of clinical mock boards and their influence on the success rate on qualifying boards. J Dent Educ 2002;66(11):1260–8.[Abstract]
- Ranney RR, Wood M, Gunsolley JC. Works in progress: a comparison of dental school experiences between passing and failing NERB candidates, 2001. J Dent Educ 2003;67(3):311–6.[Abstract]
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Abstract
Clinical experiences
