The Landscape of Predoctoral Endodontic Education in the United States and Canada: Results of a Survey

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1 Predoctoral Dental Education The Landscape of Predoctoral Endodontic Education in the United States and Canada: Results of a Survey Karl Woodmansey, DDS; Lynn G. Beck, PhD; Tobias E. Rodriguez, PhD Abstract: Few recent surveys have examined the contemporary landscape of predoctoral endodontic education in the United States and Canada, but anecdotal reports suggest that current dental students have difficulty obtaining adequate clinical endodontic experiences. The aims of this study were to quantify the clinical endodontic experiences of current U.S. and Canadian dental students, to explore the issues surrounding their clinical endodontic competence, and to ask more broadly if current graduating dentists are competent to perform endodontic procedures. In August 2014, a hyperlink to a web-based survey with 27 questions was ed to the 67 predoctoral endodontic directors of U.S. and Canadian dental schools using a list provided by the American Association of Endodontists. Out of these 67 possible participants, 40 responded, for a response rate of 60%. The findings were varied. The average 2014 graduate completed 5.9 (±2.4) root canal treatments on live patients, and 69% of the respondents voiced concern regarding a shortage of patient experiences. A majority (59%) of the respondents reported thinking that the supply of endodontic patients has decreased and that students have an inadequate supply of endodontic patients. This study found that a clear majority of predoctoral endodontics directors perceived a shortage of patient experiences for their students although, in reality, the number of completed clinical cases appeared to be unchanged since In addition, 36% of the respondents reported feeling that their 2014 graduates were not competent to perform molar endodontic treatment in their practices. Dr. Woodmansey was Associate Professor, Department of Endodontics, Texas A&M University Baylor College of Dentistry at the time of this study and is currently Associate Professor and Endodontic Program Director, Center for Advanced Dental Education, Saint Louis University; Dr. Beck is Dean and Professor, Gladys L. Benerd School of Education, University of the Pacific; and Dr. Rodriguez is Vice President for Education, Academy for Academic Leadership (AAL). Direct correspondence to Dr. Karl Woodmansey, Center for Advanced Dental Education, Room 2073, Saint Louis University, St. Louis, MO 63104; ; woodmanseykf@slu.edu. Keywords: dental education, endodontics, competency-based education, clinical education Submitted for publication 10/8/14; accepted 12/19/14 Anecdotal reports suggest that current dental students in the United States and Canada have difficulty obtaining adequate clinical endodontic experiences. 1,2 These reports infer that current students are performing fewer root canal procedures on actual patients than in the past and instead are demonstrating their competence using simulated plastic teeth. Unless otherwise compensated for, these educational deficits could affect graduates clinical endodontic competence. Our review of the literature found only four surveys on this subject published in the past 50 years. 3-6 Over that interval, significant changes have occurred in predoctoral endodontic education that may have impacted schools abilities to effectively produce competent graduates. Examples of changes include shortages of endodontist-specialist faculty members, lack of evidence-based dentistry staying current with advances in technology, and the evolving standard of care in endodontics. 4,7 Over that same time interval, educational theory and curricula have also evolved. The Commission on Dental Accreditation (CODA) defines competent as the levels of knowledge, skills, and values required by new graduates to begin independent, unsupervised dental practice. 8 Consequently, achieving competence is equated with readiness for graduation from dental school. Dental educators are responsible for developing and assessing such competence. Both CODA and the American Dental Education Association (ADEA) 9 have endorsed the model of competency-based education. Competency-based education generally replaces numeric procedural requirements with competency assessments as indicators of readiness for graduation. CODA requires that all dental schools individually define competence, develop competency assessment instruments, and provide evidence that their students have met the schools competency goals. The aims 922 Journal of Dental Education Volume 79, Number 8

2 of this study were to quantify the clinical endodontic experiences of current U.S. and Canadian dental students, to explore the issues surrounding their clinical endodontic competence, and to ask more broadly if current graduating dentists are competent to perform endodontic procedures. Materials and Methods A survey consisting of 27 questions was developed to support the aims of the study. With the approval of the study as exempt by the University of the Pacific Institutional Review Board, we distributed the survey to all predoctoral endodontic directors of U.S. and Canadian dental schools. These individuals were identified in an list provided by the American Association of Endodontists (AAE). Using that list, a hyperlink to a web-based survey was ed to the potential participants. The online survey was administered using a Qualtrics (Qualtrics LLC, Provo, UT, USA) website between August 23 and September 20, Weekly reminder s were sent to potential participants with incomplete surveys. All respondents were volunteers, with no compensation offered. The data were stored and reported anonymously by Qualtrics and were analyzed using basic descriptive statistics. Where possible, individual answers to selected categorical data questions were compared using chisquare cross-tabulation. Results Out of 67 possible respondents, 40 surveys were returned (60%), including one incompletely answered survey. The findings are summarized in Tables 1, 2, 3, 4, and 5. Off-site clinic rotations that included endodontic experiences were reported by 72% of the respondents (Table 1). At these extramural clinics, 62% of the respondents reported supervision of endodontic procedures by general dentists (Table 4). However, at the dental school clinics, only 18% reported clinical endodontic instruction by general dentists (Table 4). When asked about their most significant concerns, seven (of 39) respondents commented about inadequate endodontist faculty members. Due to the small sample sizes, chi-square statistics could be calculated on only two categorical data question pairs. With significance set at p<0.05, no statistically significant relationship was found between perceptions of dental implants affecting numbers of endodontic teeth and the perceived supply of endodontic patients for clinical treatments (p=0.27). Similarly, there was no statistically significant relationship found between students performing endodontic treatment at off-site clinics and the perceived supply of endodontic patients for clinical treatments (p=0.80). Discussion The results of this survey demonstrate the tremendous variety of approaches to predoctoral endodontic education currently used in the dental schools of the United States and Canada. When asked What is your most significant concern regarding contemporary predoctoral endodontic education?, 27 of 39 (69%) respondents voiced concern regarding a shortage of patient experiences. A slight majority (56%) of respondents felt that dental implants had (adversely) affected the numbers of teeth available for endodontic treatment. Class size was also seen as a concern as 54% of the respondents reported increased class sizes and no school s class size was reported to have decreased. Theoretically, more dental students would dilute the availability of endodontic patients. Supporting that idea, a majority (59%) of the respondents expressed the opinion that the supply of endodontic patients has decreased and that students have an inadequate supply of endodontic patients (Table 1). These findings echo the results of a 2012 study in which 69% of predoctoral directors reported a decline in the availability of predoctoral level teeth for clinical treatment. 1 In a different unpublished 2012 study of predoctoral directors, 58% responded that it has become more difficult or much more difficult for dental students to complete enough clinical endodontic cases to graduate. 10 In that second survey, 70% said that a reduced patient pool was a cause, 46% blamed an increased class size, and 60% cited more frequent recommendation of implant(s) over endodontic treatment/retreatment by non-endodontic faculty. Could these complaints be localized issues, or were they widely held misperceptions? These perceptions of endodontic patient shortages are at odds with the fact that today s dental students have quantitatively similar endodontic experiences to those of students of 39 years ago. In 1975, Serene and Spolsky August 2015 Journal of Dental Education 923

3 Table 1. Predoctoral endodontic program directors responses regarding their students education, by number and percentage of total respondents to each question Question Yes No n Do your students have an adequate supply of endodontic patients for clinical treatments? 19 (49%) 20 (51%) 39 If there are patient shortages, are simulation exercises using extracted teeth or plastic teeth 22 (56%) 17 (44%) 39 accepted as substitutes for clinical experiences? If your students use extracted human teeth for laboratory simulation exercises, do your 24 (71%) 10 (29%) 34 students have an adequate supply of these teeth? Do your dental students perform endodontic treatments at off-site clinics? 28 (72%) 11 (28%) 39 Are competency examinations (or assessments or challenges) on live patients utilized for 33 (85%) 6 (15%) 39 evaluating students clinical knowledge and skills? Are operating microscopes available for use by dental students performing endodontic 25 (64%) 14 (36%) 39 procedures? Have dental implants affected the numbers of teeth available for clinical endodontic 22 (56%) 17 (44%) 39 treatment by your school s dental students? Does your school have a graduate endodontic program? 31 (79%) 8 (21%) 39 Does your school have an AEGD or GPR program? 35 (90%) 4 (10%) 39 Table 2. Predoctoral endodontic program directors responses regarding their programs numerical requirements for graduation Standard Question Mean Range Deviation n If completing clinical treatment of a certain number of teeth is required for graduation, how many teeth are required? If completing clinical treatment of a certain number of canals is required for graduation, how many canals are required? On average, how many root canal treatments does a predoctoral student complete on human patients? Include only completed treatments, not just emergency treatments. How many hours of preclinical endodontic laboratory education do your students complete? Please report actual laboratory hours and not credit, semester, or quarter hours. How many hours of endodontic didactic lectures (total of all years) do your students complete? Please report actual class hours and not credit, semester, or quarter hours. If endodontic case portfolio(s) are required for graduation, how many portfolios are required? reported that the average dental student completed 5.6 (±1.7) endodontic treatments on patients. 3 Our survey found that number to be virtually unchanged in 2014: at 5.9 (±2.4) teeth. These numbers are not substantially different from the recommendation of a 1965 conference that stated, The predoctoral dental student should be required to treat a minimum of six pulpally involved permanent teeth. 6 The contradictory idea that current students have inadequate clinical endodontic experiences could, however, actually be true. Despite the consistent number of numerical cases, educators may be implying that this number is inadequate and that even more endodontic cases are needed to achieve competence. This belief could be driven by the complexity of endodontic treatment, by the idea that advances in endodontics technology require more time to teach and/or learn, or possibly by the evolved generational learning styles of our students. The difference between the perceptions of clinical endodontic experiences and the reality could also be partially influenced by an evolved dental school patient population. Although students may currently be treating a similar number of teeth as in years past, these teeth may require more complicated treatments than those of previous generations. There 924 Journal of Dental Education Volume 79, Number 8

4 Table 3. Predoctoral endodontic program directors responses regarding molars and retreatments in their students education, by number and percentage of total respondents (n=39) Question Required Allowed Not Permitted Clinical molar endodontic treatment experiences (not just emergency treatments) are: 16 (41%) 22 (56%) 1 (3%) Endodontic retreatment clinical experiences are: 0 17 (44%) 22 (56%) Table 4. Predoctoral endodontic program directors responses regarding who teaches and supervises endodontics in their programs, by number and percentage of total respondents (n=39) Endodontic General Not Question Endodontists Residents Dentists Applicable Who teaches or supervises your dental students clinical 39 (100%) 28 (72%) 7 (18%) 0 endodontic procedures? If your students perform endodontic treatments at off-site clinics, 12 (31%) 6 (15%) 24 (62%) 11 (28%) who supervises them? Note: Respondents could select all that apply. are no data available to ascertain the complexity of the endodontic treatments performed by predoctoral students. Schools with graduate endodontic residency programs are thought to remove the more complex patients from the predoctoral pool. These more complex cases treated by graduate endodontic residency programs most likely include molar endodontics and endodontic retreatments. Despite the trend towards competency-based education, metrics remain a de facto standard employed at many schools. All of the respondents to our survey identified a number of canals or teeth as a requirement for graduation (Table 2). Among the respondents, 29 schools require an average of 4.9 teeth for graduation, and 10 schools require an average of 8.8 canals for graduation. In 1991, Dummer reported that U.S. dental schools required an average of six teeth or 15 canals for graduation. 5 In 1981, Mendel and Sheets reported average requirements of between 12.9 and 13.9 canals, depending on the size of the dental school. 4 Clinical patient encounters are not the only metrics used for assessing competence. Other common assessment techniques include objective structured clinical examinations (OSCEs), competency examinations (using either live patients or simulations), and portfolios Regarding assessments, our survey found 85% of the responding schools use endodontic competency assessment examinations using live patients and 21% use portfolio evaluations. When reporting grades, 21% use a pass/fail system. Table 5. Predoctoral endodontic program directors perceptions of whether their schools 2014 graduates were competent to perform molar endodontic treatment in their practices, by number and percentage of total respondents (n=39) Answer Number Percentage Yes 14 36% No 14 36% Uncertain 11 28% A 2012 survey found that when patient shortages did occur, 46% of the predoctoral directors allowed compensatory simulation experiences using plastic or extracted human teeth. 10 Our survey found 56% of the responding schools permit such substitutions. In the preclinical laboratory, 84% of respondents reported using at least some extracted human teeth, and 29% reported having an inadequate supply of human teeth. In addition, 84% reported using at least some plastic teeth in the preclinical laboratory, which may be related to the fact that all licensure exams, except the Western Regional Examining Board (WREB) exam, now utilize plastic teeth for the endodontic component. In our survey, 64% of the respondents claimed that their programs have operating microscopes available for use by dental students performing endodontic procedures. Although having microscopes available, training students to a competent level, and August 2015 Journal of Dental Education 925

5 actually using the microscopes are separate issues, the fact that microscopes are available by a majority of schools is noteworthy. This majority percentage could suggest the complex level of cases currently being treated at the predoctoral level, or it could demonstrate the commitment of these programs to teaching to the highest standard of care. CODA mandates that graduate endodontic residents are trained in the use of operating microscopes, but it remains silent regarding predoctoral endodontic education. 8,15 If microscopes are the de facto standard of care for endodontists, shouldn t general dentists be trained to the same standard? 16 The larger questions may be how to achieve microscopic competence with only a limited number of clinical cases and if operating microscopes should also be included in preclinical laboratory training. A group of endodontic educators in 1965 recommended that 36 to 46 clock hours of laboratory and didactic instruction should be the minimum in preparing predoctoral dental students for the clinical practice of endodontics. 6 In 1975, Serene and Spolsky reported that students averaged 26.3 (±17.8) hours of preclinical laboratory experience. 3 In 1991, Dummer reported an average of 34 hours. 5 Our survey found an average of 53.0 (±19.1) hours. When tallying the average number of hours of didactic endodontic lectures over students entire dental school career, Serene and Spolsky reported 37.5 hours, 3 and we found 33.6 hours. Of the predoctoral directors surveyed in 2012, 53-60% reported requiring endodontic treatment of molars. 1 Our survey found only 41% percent of the responding schools required molar endodontic cases, 56% permitted such cases, and one school did not allow predoctoral students to do molar endodontics. When asked, In general, are your school s 2014 graduates competent to perform molar endodontic treatment in their practices?, 36% of the respondents said no, 36% said yes, and 28% were uncertain (Table 5). A similarly phrased question in 2012 yielded 65% no, 10% yes, and 24% uncertain responses. 1 The discrepancy between these surveys results may be at least partially explained by the subjectivity of the question and the interyear variability of graduates. Assessing endodontic competence is a difficult and sometimes nebulous effort. Each school individually defines endodontic competence without any national standard. The licensure examinations of the United States and Canada may represent the most universal determinations of endodontic competence. However, none of the current licensure examinations require clinical endodontic treatment of a live patient. Instead, they all rely on simulation examinations using plastic or extracted human teeth. Consequently, schools may focus their preparatory efforts on simulation exercises instead of live-patient experiences. Like all survey research, this study had several notable limitations. Because not all predoctoral directors responded to the survey, the data set was incomplete and may not be fully representative of the entirety of predoctoral endodontics. As with any survey, the individual respondents may have biases that influenced their responses. Some questions intentionally asked for subjective responses. For example, asking whether 2014 graduates were competent to perform molar endodontic treatment is a highly subjective question. Because competence itself is subjective, we considered this an appropriate query. Conclusion Endodontic educators are challenged to help their students achieve competence in a short period of time with only a handful of clinical case experiences. Our study found that a majority of the responding predoctoral endodontic directors perceive a shortage of patient experiences for their students. The survey data reported here found the current number of experiences to be 5.9 (±2.4) teeth. In reality, however, the number of completed clinical cases appears essentially unchanged since Additional research is needed to better elucidate factors affecting the perceptions of inadequate patient experiences. This survey also asked the overarching question, Are today s dental graduates competent to perform endodontic procedures? Of the respondents, 36% reported feeling their 2014 graduates were not competent to perform molar endodontic treatment in their practices. Future surveys should explore the educational efforts defining endodontic competence and the relationships among competence assessed by dental schools, competence assessed by board examinations, and the self-assessed competence of new graduates. Acknowledgments The authors thank the AAE for sharing its list of predoctoral endodontics program directors. This research represents Dr. Woodmansey s partial fulfillment of the requirements for the degree of Master of Arts in Education from the University of the Pacific Benerd School of Education and AAL. 926 Journal of Dental Education Volume 79, Number 8

6 Disclosure The authors have no financial, economic, or professional interests that may have influenced the design, execution, or presentation of this research. REFERENCES 1. AAE Educational Affairs Committee American Association of Endodontists predoctoral directors educators workshop: audience response system survey results. Chicago: American Association of Endodontists, Archer R. How can the decreased number of cases at the predoctoral level and its impact on competencies be addressed. Eye on Education: AAE s Monthly Update for Educators, Sept. 2014:2. 3. Serene TP, Spolsky V. Survey of predoctoral endodontic curricula. J Dent Educ 1975;39(2): Mendel RW, Sheets JP. Characteristics of predoctoral endodontic education in the United States and Canada. J Dent Educ 1981;45(11): Dummer PMH. Comparison of predoctoral endodontic teaching programs in the United Kingdom and in some dental schools in Europe and the United States. Int End J 1991;24: Proceedings of the Conference on the Teaching of Endodontics, Ann Arbor, MI, April 1965: Glickman GN, Gluskin AH, Johnson WT, Lin J. The crisis in endodontic education: current perspectives and strategies for change. J Endod 2005;31(4): Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, American Dental Education Association. ADEA competencies for the new general dentist. J Dent Educ 2014;78(7): Schweitzer J. Acrylic teeth in dental education. Presentation, American Association of Endodontists Predoctoral Directors Educators Workshop, Chicago, Aug Hendricson WD. Appropriate assessments for competency-based education. ADEA CCI Liaison Ledger, Nov At: Liaison-Ledger/GuestPerspective/Pages/November- 2008CCIGuestPerspective.aspx. Accessed 28 Sept Accreditation Council for Graduate Medical Education and American Board of Medical Specialties. Toolbox of assessment methods, version 1.1. Chicago: Accreditation Council for Graduate Medical Education and American Board of Medical Specialties, Holmboe E, Sherbino J, Long D, et al. The role of assessment in competency-based medical education. Med Teach 2010;32: Chambers DW. Portfolios for determining initial licensure competency. J Am Dent Assoc 2004;135: Commission on Dental Accreditation. Accreditation standards for advanced specialty education programs in endodontics. Chicago: American Dental Association, Ruddle CJ. Endodontic standard of care. Dent Today 2006;25(7):12,14,16. August 2015 Journal of Dental Education 927