Does the Sequence of Preclinical Dental

Crown Type Preparations Affect Evaluation

Scores?
Tom V. Korioth, DDS, PhD; Michael A. McBride, DDS
Abstract: Preclinical dental students must demonstrate aptitude in the preparation of teeth for treatment with several types of
fixed dental prostheses. The optimal sequence of instruction and examination of these crown preparations in preclinical fixed
prosthodontics is unknown. The aim of this study was to determine if grading scores by faculty and students were affected by
changing the sequence of crown type preparations. Practical exams of two successive student cohorts (n=89 in 2014; n=92 in
2015) at one U.S. dental school using three crown preparations (full cast, porcelain fused to metal, and all-ceramic) in different
order were analyzed by faculty grades and student self-assessment. All of the models indicated that the sequence in which the
crown type preparations were taught did have an effect on the grades. The 2014 cohort had overall higher grades and particularly
higher grades for the all-ceramic crown preparations. Evaluation scores were affected by the sequence in which the different
crown type preparations were taught and tested. Although the overall results suggested that students may perform better if the
all-ceramic crown preparation is taught last, this tendency may differ between years.
Dr. Korioth is Professor and Director of Fixed Prosthodontics, Department of Prosthodontics, College of Dentistry, University of
Tennessee Health Science Center; and Dr. McBride is Associate Professor and Director of Clinical Education, Office of Clini-
cal Affairs, College of Dentistry, University of Tennessee Health Science Center. Direct correspondence to Dr. Tom V. Korioth,
Department of Prosthodontics, College of Dentistry, University of Tennessee Health Science Center, Room C-515 Dunn Bldg.,
875 Union Ave., Memphis, TN 38163; 901-448-6930; [email protected].
Keywords: dental education, prosthodontics, crowns, fixed dental prosthesis, self-assessment
Submitted for publication 1/4/16; accepted 6/15/16

I
n preclinical fixed prosthodontics, dental students The ideal sequencing of competencies in
must demonstrate proficiency when preparing fixed prosthodontics is still unknown. Historically,
teeth to receive different crown types: full cast the order of crown preparation practicals has been
crown (FCC), porcelain fused to metal (PFM), or all- based on adopted or inherited teaching methods of
ceramic (AllCER). For practice, these preparations established curricula. At the University of Tennessee
are done multiple times per crown type to improve Health Science Center College of Dentistry (UTHSC
motor skills and to develop abilities needed to pass COD), second-year dental students take three practi-
the fourth-year mock boards and the dental licensure cal examinations or competencies during their single-
mannequin exam.1 A significant relationship has been unit fixed dental prostheses (FDP) course—one for
found between passing the mock board fixed prosth- each crown type. Traditionally, students have started
odontic preparation and the successful completion of out with FCC, moved on to PFM, and finished with
that procedure on the state licensure exam.2 AllCER crowns. The sequence was changed for 2015
Evaluation outcomes in preclinical fixed so that students started out with AllCER, moved on
prosthodontics have been correlated with digital tooth to FCC, and ended with PFM preparations. All of the
preparation analysis,3 shortened preclinical exercis- practical exams conform to the ones taught at various
es,4 and the use of instructional videos and computer- U.S. dental schools.11
based simulations,5 among others. Self-assessment, in The aim of our study was to determine if grad-
which students rate their own performance against a ing scores by faculty and students were affected by
standard, has been found to contribute to active learn- changing the sequence of crown type preparations.
ing.1 Whereas studies have shown lack of evaluation This knowledge could be used to enhance preclinical
accuracy in self-assessment,6-8 others have reported outcomes in fixed prosthodontics by better streamlin-
that self-assessment improves learning motivation ing students’ tooth preparation skills.
and higher achievement.9,10

December 2016  ■  Journal of Dental Education 1457

 randomly chosen preparations were graded by both
Methods examiners, yielding an inter-examiner correlation
(Pearson’s r) coefficient of 0.51. Students were
The study was determined to be exempt from
awarded final bonus points on the basis of scoring
oversight by the Institutional Review Board at the
differences: no difference or perfect grading match
University of Tennessee Health Science Center.
was awarded with +2 additional grade points, and the
Past grading data on full coverage single unit FDP
largest difference (either large under- or overgrad-
preparations were collected for three independent
ing by students) was penalized with a deduction of
exams over two years. Two successive cohorts of
-2 from the final grade. Scoring was done without
second-year dental students (89 students in 2014 and
knowledge of students’ identities.
92 students in 2015) were chosen for the study. The
The distribution of data was analyzed for
total sample size was based on a 2 (years) x 3 (exams)
normality of errors of residuals. Student’s t-tests
x 2 (evaluations) data matrix. Student confidentiality
were used to compare grading scores to determine
was maintained.
differences between years. A linear mixed model was
Over the course of three months during their
used to compare the trajectories of the grades over
second year, the students took three different practical
the course of the semester, while accounting for the
examinations involving the preparation of a specific
correlation for each student and within each year.
ivorine tooth on a typodont (ModuPRO Pros, Aca-
All statistical analyses were performed using SAS/
dental Inc., Overland Park, KS, USA) attached to
STAT, version 9.4 (SAS Institute, Cary, NC, USA).
a mannequin (KaVo Dental, Charlotte, NC, USA).
A difference of p≤0.01 was considered to be statisti-
Each of the three crown preparations (FCC, PFM,
cally significant.
and AllCER) was thus tested independently. Each
exam lasted two and a half hours, which included the
preparation itself plus the fabrication of an interim
FDP on the cut artificial tooth. Prior to each practical Results
exam, students received pertinent lectures on design The normality of the data is shown in Figure
and technique as well as approximately ten to 12 1 for faculty scores and Figure 2 for student evalu-
hours of supervised lab instruction specific for the ations. The t-tests revealed a very significant dif-
preparation type. Evaluation criteria were explained ference between the two instruction years but for
to the students before each exam in an attempt to all-ceramic crown scores only, both for faculty and
improve self-assessment accuracy. At the end of the student assessments. For all exams, students evalu-
examination period, students were given 15 minutes ated themselves higher than did the faculty (Table 1).
to grade their tooth preparation on pre-designed All of the linear mixed models (faculty and
evaluation sheets (available from the corresponding students) that compared the trajectory or sequence of
author). Ratings were based on students’ ability to the grades over the course of the semester indicated
cut a tooth to conform to specific dimensions. that the order in which the crowns were taught did
For each exam and tooth preparation, a total have an effect on the students’ scores (statistical data
of 21 variables were evaluated. These were divided available from the corresponding author). The 2014
into three groups: Clinical Perception (five variables), preparation grades resulted in overall higher grades
Measurements (11 variables), and Provisional (five and particularly higher scores on the all-ceramic
variables). The grades were based on the Clinical crown exam than the 2015 scores (Figure 3 and
Perception and Measurements categories only, with Figure 4).
the latter having a larger amount of measurable
(objective) variables to improve self-assessment ac-
curacy. The students circled the deficiencies on their
evaluation sheet, with possible deductions being of
Discussion
-2, -4, or -10 points for each variable in increasing The optimal sequence of crown type prepara-
order of importance. tions in preclinical fixed prosthodontics is unknown.
Two trained faculty members with previous Our study addressed this by comparing the scores of
grading experience assessed the examinations in two student cohorts. Scoring grades improved over
random order for every event and both years. To time, regardless of crown type preparation sequence.
establish a measure of interrater reliability, five Students improved their grades when they started

1458 Journal of Dental Education  ■  Volume 80, Number 12

Figure 1. Normality in distribution of errors of residuals for faculty scores, with predicted means and quantiles

with a full cast crown and ended up with an all- a higher amount of tooth structure removal when
ceramic FDP preparation (year 2014) or when they compared to a full cast crown preparation.
started out with the all-ceramic preparation followed Students’ self-evaluations were consistently
with the full cast crown and ended with the porcelain higher than those by the faculty members, corrobo-
fused to metal exam. This result appeared to be true rating the findings of others that indicated students’
for both faculty and student scores. However, the tendency to overestimate their preclinical dental
scoring differences between the all-ceramic groups restorative work.12-14 However, when student self-
were the most significant and stood out clearly from assessments were compared with peer assessments
the two other crown type preparations. Although and faculty scores, the differences were not sig-
the first practical crown preparation exams yielded nificant in another study.15 A possible reason may be
the lowest scores for both years, possibly also due inconsistent inter-examiner agreement.16-18 Another
to a lack of familiarity with the examination system source of variability lies in the lack of the students’
as well as practical skills, our results contradict the improvement in their ability to self-evaluate their
reasoning of first teaching a crown preparation like work, with poorer performing students being unable
an all-ceramic one that is more “forgiving” due to to realistically evaluate their own projects and rating

December 2016  ■  Journal of Dental Education 1459

 Figure 2. Normality in distribution of errors of residuals for students’ self-evaluation scores, with predicted means and
quantiles

their skills highest and the higher performing students shape analysis into the curriculum.25 Although a
rating themselves lower than anticipated.19,20 computer-generated scan has been found to be more
Preclinical student self-assessment in re- precise than the hand-graded traditional method,26 as
storative dentistry has been analyzed in cross- well as preferred by students,27 it may also lack good
sectional12,13 and longitudinal studies.19-21 In general, correlation with conventional grading by standard-
longitudinal studies have demonstrated the benefits ized faculty, possibly due to the limitation of the
of self-assessment by showing improved agreement grading software to include all pertinent evaluation
over time in scoring between faculty and students22 criteria.21 It is clear that current computer-aided sys-
and an enhancement in assessment recognition tems with immediate feedback capabilities are ideal
skills.23 In this sense, Curtis et al. reported that an instruments for unbiased, on-time self-assessment
improvement in student self-assessment predicted in preclinical fixed prosthodontics instruction. How-
an improvement in examination scores among dental ever, it is the sequencing of instruction or exams,
students who were completing a preclinical complete even with the latest technology, that can also have a
removable dental prosthesis tooth setup.24 significant impact on outcomes. The sequencing of
An enhancement in students’ self-assessment instruction material has been studied earlier in other
could be obtained by incorporating digital software academic fields such as chemistry, mathematics, and

1460 Journal of Dental Education  ■  Volume 80, Number 12

Table 1. Scoring statistics for 2014 and 2015 by scoring group and crown types
Scoring 2014 2015 p-value

Faculty
FCC
Mean±sd 84.3±6.5 84.4±6.9 0.88
Median (range) 86 (60-94) 84 (60-96)
PFM
Mean±sd 84.3±6.4 84.3±7.1 0.96
Median (range) 86 (60-96) 86 (62-96)
AllCER
Mean±sd 87.7±5.5 82.7±8.2 <0.001
Median (range) 88 (66-98) 84 (60-96)
Students
FCC
Mean±sd 85.3±5.5 84.6±5.0 0.40
Median (range) 86 (67-98) 84 (72-98)
PFM
Mean±sd 86.1±4.9 86.9±5.3 0.33
Median (range) 86 (70-94) 87.5 (70-98)
AllCER
Mean±sd 89.2±4.2 85.1±5.2 <0.001
Median (range) 90 (74-98) 86 (70-96)
Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015. The p-values were determined with Student’s t-test. Scoring was done by two faculty members in both years and by
89 students in 2014 and 92 students in 2015.

Figure 3. Faculty scores (least squares means) for all three crown preparations by year

Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015.

December 2016  ■  Journal of Dental Education 1461

 Figure 4. Students’ self-evaluation scores (least squares means) for all three crown preparations by year

Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015.

psychology. The results have shown that outcomes lower intra- than inter-examiner variability overall.17
were positively influenced by order in difficulty of Ideally, a higher number and standardized training
test questions,28 the application of cognitive load of assessors and more objective measurement tools
theory by repetitive, sequential teaching to engage could improve the reliability of the scores.31 Accord-
more of the long-term memory,29 and the sequence ing to Chambers and LaBarre, simple adjustments
of degree in difficulty of the instruction material.30 to judgment scores can be made more effective than
In the case of our program at UTHSC, the grading checklists or faculty calibration.32 An im-
choice of FDP sequence with all-ceramic crown provement in inter-examiner agreement or scoring
preparation last is now based on a better integra- consistency could be achieved by either increasing
tion with the remaining restorative curriculum, the number of standardized evaluators (minimum
especially due to the general tendency towards the of three with seven needed to obtain a very strong
use of more all-ceramic materials. In this sense, correlation coefficient) or dramatically simplifying
we reverted to the past sequence in which we start the scoring criteria.33
preclinical fixed instruction over one academic
year with an FCC single unit FDP and end it with
multi-unit all-ceramic bridgework. This sequence Conclusion
also allows for more seamless integration with our
CAD/CAM course. In this study, the evaluation scores were af-
One of the limitations of our study was the low fected by the sequence in which the different crown
number of faculty graders. While intra-examiner type preparations were taught and tested. Crown
variability was not assessed, the individual teaching/ preparation grades improved significantly over time
grading experience of both examiners (30+ years with an increase in number of practical exams, with
combined) and published data indicate a generally the all-ceramic crown preparations resulting in the

1462 Journal of Dental Education  ■  Volume 80, Number 12

most significant differences. Although the overall comparison with experienced assessors. Eur J Dent Educ
results suggest that students may perform better if 2008;12(2):99-102.
16. Jenkins SM, Dummer PM, Gilmour AS, et al. Evaluating
the all-ceramic crown preparation is taught last, this
undergraduate preclinical operative skill: use of a glance
tendency may differ between years. and grade marking system. J Dent 1998;26(8):679-84.
17. Sharaf AA, AbdelAziz AM, El Meligy OA. Intra- and
Acknowledgments inter-examiner variability in evaluating preclinical
pediatric dentistry operative procedures. J Dent Educ
Our gratitude goes to Vikki Nolan, DSc, MPH, 2007;71(4):540-4.
from the Biostats, Epidemiology, and Research De- 18. Quinn F, Keogh P, McDonald A, Hussey D. A study
sign Clinic at UTHSC for her professional statistical comparing the effectiveness of conventional training and
help. virtual reality simulation in the skills acquisition of junior
dental students. Eur J Dent Educ 2003;7(4):164-9.
19. Cho GC, Chee WW, Tan DT. Dental students’ ability to
REFERENCES evaluate themselves in fixed prosthodontics. J Dent Educ
1. Hauser AM, Bowen DM. Primer on preclinical instruction 2010;74(11):1237-42.
and evaluation. J Dent Educ 2009;73(3):390-8. 20. Tuncer D, Arhun N, Yamanel K, et al. Dental students’
2. Stewart CM, Bates RE Jr, Smith GE. Does performance on ability to assess their performance in a preclinical re-
school-administered mock boards predict performance on storative course: comparison of students’ and faculty
a dental licensure exam? J Dent Educ 2004;68(4):426-32. members’ assessments. J Dent Educ 2015;79(6):658-64.
3. Gratton DG, Kwon SR, Blanchette D, Aquilino SA. Im- 21. Callan RS, Haywood VB, Cooper JR, et al. The validity
pact of digital tooth preparation evaluation technology on of using E4D Compare’s “% comparison” to assess crown
preclinical dental students’ technical and self-evaluation preparations in preclinical dental education. J Dent Educ
skills. J Dent Educ 2016;80(1):91-9. 2015;79(12):1445-51.
4. Sukotjo C, Thammasitboon K, Howell H, Karimbux 22. Geissler PR. Student self-assessment in dental technology.
N. The impact of targeted shortened preclinical exer- J Dent Educ 1973;37(9):19-21.
cises on student perceptions and outcomes. J Dent Educ 23. Knight GW, Guenzel PJ, Fitzgerald M. Teaching
2007;71(8):1070-9. recognition skills to improve products. J Dent Educ
5. Aragon CE, Zibrowski EM. Does exposure to a procedural 1990;54(12):739-42.
video enhance preclinical dental student performance in 24. Curtis DA, Lind SL, Dellinges M, et al. Dental students’
fixed prosthodontics? J Dent Educ 2008;72(1):67-71. self-assessment of preclinical examinations. J Dent Educ
6. Falchikov N. Involving students in assessment. Psychol 2008;72(3):265-77.
Learn Teach 2003;3(2):102-8. 25. McPherson KR, Mennito AS, Vuthiganon J, et al. Utilizing
7. Woolliscroft JO, TenHaken J, Smith J, Calhoun JG. self-assessment software to evaluate student wax-ups in
Medical students’ clinical self-assessments: comparisons dental morphology. J Dent Educ 2015;79(6):697-704.
with external measures of performance and the students’ 26. Renné WG, McGill ST, Mennito AS, et al. E4D Compare
self-assessments of overall performance and effort. Acad software: an alternative to faculty grading in dental educa-
Med 1993;68(4):285-94. tion. J Dent Educ 2013;77(2):168-75.
8. Arnold L, Willoughby TL, Calkins EV. Self-evaluation in 27. Hamil LM, Mennito AS, Renné WG, Vuthiganon J. Dental
undergraduate medical education: a longitudinal perspec- students’ opinions of preparation assessment with E4D
tive. J Med Educ 1985;60(1):21-8. Compare software versus traditional methods. J Dent
9. Falchikov N, Boud D. Student self-assessment in higher Educ 2014;78(10):1424-31.
education: a meta-analysis. Rev Educ Res 1989;59:395- 28. Hodson D. The effect of changes in item sequence on
430. student performance in a multiple-choice chemistry test.
10. McMillan JH, Hearn J. Student self-assessment: the key J Res Sci Teach 1984;21(5):489-95.
to stronger student motivation and higher achievement. 29. Clarke T, Ayres P, Sweller J. The impact of sequencing and
Educ Horizons 2008;87(1):40-9. prior knowledge on learning mathematics through spread-
11. Petropoulos VC, Weintraub A, Weintraub GS. Predoc- sheet applications. Educ Technol Res Dev 2005;53(3):
toral fixed prosthodontics curriculum survey. J Prosthod 15-24.
1998;7(3):183-91. 30. McDade CE. Subsumption versus educational set: impli-
12. Ahmed A, Jalil S, Sikandar M. Accuracy of self evaluation cations for sequencing of instructional materials. J Educ
of crown preparations by 2nd year preclinical students. Psychol 1978;70(2):137-41.
Pakistan Oral Dent J 2012;32(2):319-21. 31. Taylor CL, Grey N, Satterthwaite JD. Assessing the clini-
13. Kirov D, Kazakova S, Kirilova J. Students’ self-assess- cal skills of dental students: a review of the literature. J
ment in preclinical and clinical education of prosthetic Educ Learn 2013;2(1):20-31.
dentistry. JIMAB 2014;20(23):575-7. 32. Chambers DW, LaBarre EE. Why professional judg-
14. Foley JI, Richardson GL, Drummie J. Agreement among ment is better than objective description in dental fac-
dental students, peer assessors, and tutor in assessing ulty evaluations of student performance. J Dent Educ
students’ competence in preclinical skills. J Dent Educ 2014;78(5):681-93.
2015;79(11):1320-4. 33. Chambers DW. Issues in transferring preclinical skill learn-
15. Satterthwaite JD, Grey NJ. Peer-group assessment of ing to the clinical context. J Dent Educ 1987;51(3):238-43.
preclinical operative skills in restorative dentistry and

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