Effect of Dental Practicality Index training using an online video on decision-making and confidence level in treatment planning by dental undergraduates

Article information

Restor Dent Endod. 2024;49.e8

Publication date (electronic) : 2024 January 24

doi : https://doi.org/10.5395/rde.2024.49.e8

Zhai Wei See¹, Ming Sern Lee¹, Abhishek Parolia^1,2, Shalini Kanagasingam³, Shilpa Gunjal¹, Shanon Patel⁴

¹School of Dentistry, International Medical University, Kuala Lumpur, Malaysia.

²Department of Endodontics, University of Iowa College of Dentistry and Dental Clinics, Iowa City, IA, USA.

³School of Dentistry, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, United Kingdom.

⁴Department of Endodontology, King’s College London Dental Institute, London, United Kingdom.

Citation: See ZW, Lee MS, Parolia A, Kanagasingam S, Gunjal S, Patel S. Effect of Dental Practicality Index training using an online video on decision-making and confidence level in treatment planning by dental undergraduates. Restor Dent Endod 2023;49(1):e8.

Correspondence to Abhishek Parolia, BDS, MDS, MFDS RCPS (Glasgow), MFDS RCS (Edinburgh), PhD. Department of Endodontics, University of Iowa College of Dentistry and Dental Clinics, 801 Newton Rd, Iowa City, IA 52242, USA. abhishek-parolia@uiowa.edu

Correspondence to Shanon Patel, BDS, MSc, MClinDent, MRD, FDS, FHEA, PhD. Department of Endodontology, King’s College London Dental Institute, Guy’s Tower, Guy’s Hospital, St. Thomas’ Street, London SE1 9RT, United Kingdom. shanonpatel@googlemail.com

Received 2023 October 15; Revised 2023 November 14; Accepted 2023 November 14.

Abstract

INTRODUCTION

Treatment planning is one of the most important skills for dental undergraduates (DUs) to develop in preparation for clinical practice [1]. It can be challenging and requires the clinician to consider many interrelated factors to devise a coherent treatment plan. Ali et al. [2] observed that DUs were relatively unconfident in formulating a comprehensive treatment plan and knowing when to refer a case.

Various guides for treatment planning have been published, but they have often been considered either too time-consuming or complex to be of practical benefit, resulting in a poor uptake among clinicians. Similarly, multiple treatment planning tools have been in use; however, they have been limited to single aspects of dental treatment instead of providing the holistic approach necessary for comprehensive treatment planning [3456].

The Tooth Restorability Index (TRI) quantifies the volume of the remaining dentin and its position as a numerical score to determine the restorability of a tooth [7]. However, this index only focuses on the restorability of a tooth and does not include any other aspect, such as the patient's oral health.

The American Association of Endodontists Endodontic Case Difficulty Assessment takes 17 aspects of endodontic treatment-related factors into consideration and assesses the difficulty of each aspect. It includes patient factors, such as medical history, as well as treatment considerations, such as tooth position and radiographic findings [6]. However, due to its complexity and time-consuming nature, the guide is used by fewer than 10% of American general dental practitioners [3].

The Restorability Dentistry Index of Treatment Need is an index that identifies dental restorative treatment needs and then ranks them by complexity. The complexity of each need is scored as low, moderate, or high. A modifying factor specific to each component can be applied. However, due to the lack of reproducibility of the root canal treatment assessment component, the uptake of this index is low [89].

Dawood and Patel [10] introduced the Dental Practicality Index (DPI), which aims to provide clinicians with a TRI that takes into account the structural integrity, periodontal status, endodontic status and weighs these factors in relation to the status of the tooth within the dentition as a whole, as well as any relevant medical or dental history and the patient’s unique dental needs (Table 1). The score of each aspect is then added to give the DPI score. According to the DPI, a score of 0 refers to no treatment, a score of 1 refers to simple treatment is required, and a score of 2 suggests that treatment is more complex, perhaps requiring treatment delivered by individuals with enhanced skills, training, and experience. A score of 6 in any category denotes that the tooth is considered untreatable. The DPI is applicable to everyday clinical practice as it encourages clinicians to plan treatment methodically and holistically. It also helps to improve confidence in assessing which treatments are within the clinician’s competency and when additional training or referral to another clinician may be required to complete the treatment.

Table 1

Explanation of the Dental Practicality Index (Dawood and Patel [10])

The effectiveness of the DPI in predicting the outcome of root canal retreatment and restoration of root-filled teeth has been reported in clinical studies [111213]. The lack of a systematic protocol could lead to incorrect clinical decision-making. The DPI provides a methodical approach by assessing factors pertaining to restorability, endodontics, periodontics, and patients’ unique needs [14].

A multi-center study involving undergraduate and postgraduate students demonstrated that training with the DPI improved the consistency of treatment planning involving a variety of restorative dental problems, when compared to the decisions made by a consensus panel of experienced dental clinical educators. The study methodology utilized a test-retest method and a confidence questionnaire, using a 10-point Likert scale [15].

Over the past 2 decades, there has been an exponential growth in the demand for online-based teaching and learning, and this trend has been exacerbated by the COVID-19 pandemic [16]. There has also been a shift in the delivery of education towards a blended approach of traditional and online-based teaching and learning [17].

Therefore, the current study was conducted to evaluate the effect of DPI training using an online video on the treatment planning decisions and confidence level of DUs.

MATERIALS AND METHODS

DPI training

The DPI training was standardized. Examiners were trained and calibrated to carry out DPI training and to collect, insert, and interpret the data. In this research, all DUs participated online. To assess their baseline knowledge, they were shown 15 clinical case scenarios (pre-DPI training test, which is the control) and instructed to decide on appropriate treatment plans based on 4 treatment options: no treatment needed, simple treatment needed, complex treatment needed, leave/extract the teeth (Figure 1). The most appropriate treatment plan for these clinical case scenarios had been decided by the consensus panel, similar to a previous study [14]. They then underwent DPI training by using the online-based interactive video and PowerPoint presentation slides. After that, DUs were shown the same clinical case scenarios and asked to assign one of the 4 treatment plan options according to the DPI (post-DPI training test). The pre-DPI training test, DPI training, and post-DPI training test were held on the same day. For all tests, the 15 case scenarios were shown on Microsoft Teams (Microsoft 365, Microsoft Corp.). The DUs were requested to choose the appropriate treatment option and answer through Microsoft Form (Microsoft 365, Microsoft Corp.). One minute was given for reading and answering each case scenario to avoid any discussion among students.

Figure 1

A clinical case scenario used in the tests, with 4 treatment options assigned.

RCT, root canal treatment.

After 6 weeks, the DUs were retested to assess their knowledge retention (retention test). They were required to retake the test by using the same set of case scenarios in a different sequence to avoid any memory-based bias. In all 3 tests, DUs completed the 10-point Likert confidence level scale questionnaire based on Academic Behavioral Confidence (ABC) scale using Microsoft Forms.

RESULTS

After checking individuals’ eligibility, a total of 94 DUs participated in the study (included in the study, completed follow-up, and analyzed) (Figure 2). From that, there were 53 (56.4%) and 41 (43.6%) participants from the year 4 and year 5 cohorts, respectively. The study participants consisted of 24 (25.6%) men and 70 (74.4%) women, with an age range of 22–28 years.

Figure 2

Number of dental undergraduates who participated in each stage of the study.

DPI, Dental Practicality Index.

DUs’ responses

Overall, the total mean treatment planning scores increased from the pre-DPI training test (control) (7.53) to the post-DPI training test (9.01) and the difference was found to be statistically significant (p < 0.001). After 6 weeks, the mean treatment planning scores decreased marginally from the post-DPI training test score of 9.01 to the retention test score of 8.87, and the difference was found to be statistically not significant (p = 0.563) (Figure 3).

Figure 3

Mean treatment planning scores of year 4 and year 5 dental undergraduates and self-reported confidence level for all dental undergraduates.

DPI, Dental Practicality Index.

The mean treatment planning scores for the year 4 and year 5 DUs in the pre-DPI training test (control) were found to be 7.43 and 7.66, respectively. Following the DPI training, the treatment planning scores increased to 9.09 and 8.90 for year 4 and year 5, respectively. There was a statistically significant difference between the mean pre-DPI training test (control) and the post-DPI training test scores for the year 4 (p = 0.001) and year 5 (p = 0.004) cohorts. For the retention test after 6 weeks, both cohorts scored slightly lower than the post-DPI training test, with the scores of 8.92 and 8.80 for the year 4 and year 5 DUs, respectively (Figure 3), showing statistically no significant difference for both cohorts (year 4: p = 0.631; year 5: p = 0.709).

The independent-samples Mann-Whitney U test showed no statistically significant differences between the cohorts in any of the 3 tests (pre-DPI training test: p = 0.528; post-DPI training test: p = 0.580; and retention test: p = 0.930).

Comparison of dental undergraduates’ responses

A comparison of 94 DUs’ answers in the pre-DPI training (control), post-DPI training, and retention tests to the consensus panel answers is given in Tables 2-4.

Table 2

Comparison of responses from the consensus panel with responses from DUs in the pre-Dental Practicality Index (DPI) training test

Table 4

Comparison of responses from the consensus panel with responses from DUs in the retention test

In the pre-DPI training test (control), most DUs agreed with the consensus panel in 8 out of the 15 clinical scenarios. The percentage of agreement varied from 16.0% to 91.5% (Table 2). After DPI training, the results improved, as the majority of DUs agreed with the consensus panel in 10 out of the 15 clinical scenarios in both the post-DPI training test and the retention test. The percentage of agreement varied from 30.9% to 86.2% in the post-DPI training test (Table 3), while it varied from 28.7% to 90.4% in the retention test (Table 4).

Table 3

Comparison of responses from the consensus panel with responses from DUs in the post-Dental Practicality Index (DPI) training test

There was a high degree of intra-rater reliability, with a range of 29.8% to 75.5% (mean 49.3%) of the DUs giving the same answer to a clinical scenario in the pre-DPI training test (control) and post-DPI training test. Following DPI training, 12.8% to 41.5% (mean 25.7%) of the DUs changed their answers to agree with the consensus answer in the post-DPI training test. There were 12.8% to 72.3% (mean 41.0%) of them who maintained the answers that agreed with the consensus panel in the retention test when compared to the post-DPI training test (Table 5).

Table 5

Summary of intra-rater reliability and how DUs changed their answers following Dental Practicality Index (DPI) training

DISCUSSION

Clinical decision-making is an essential aspect of treatment planning for dentists; however, this can be challenging without the use of a systematic framework. A dentist’s training, competency, and confidence are the main factors that impact decision-making. Studies have reported considerable inter-clinician variability in decision-making for managing endodontic conditions based on postgraduate training [1819]. The secondary factors are patient preferences, environmental factors, and resource-related factors such as equipment and material availability. Considerable bias arises from many sources of uncertainty, including the limitations of human memory and judgment [20].

The current study observed a significant improvement in the treatment planning decision-making of DUs following training on DPI, achieving a greater level of agreement with the consensus panel. In this study, 2 different cohorts of DUs were chosen to minimize the sampling bias. The knowledge of DUs was taken into account by conducting a baseline test that served as the control in the research and measuring the change in scores for each dental undergraduate following DPI training. The internal validity was improved by managing confounding variables, such as by restricting the time to answer each question in test to prevent DUs from discussing and influencing each other. The pre-DPI training test and post-DPI training test were conducted on the same day, which ensured 100% participation throughout the study. We discussed administering the pre-DPI training test and post-DPI training test on 2 different days, to allow more time for the DUs to become familiar with utilizing the DPI; however, it would have been very difficult to ensure that the other teaching and learning activities would not affect the accuracy of the results and further compromise the outcome of the research. Therefore, to reduce this risk, pre-DPI training test and post-DPI training test of the study were conducted on the same day.

Retention of knowledge from the DPI training was assessed with a retention test 6 weeks after the post-DPI training test. Previous research has suggested that the rate of knowledge retention could decrease substantially after the post-test and even be equivalent to the pre-test after approximately 2 months (55 days) [21]. Taking the research findings into consideration, we chose 6 weeks as the time frame for conducting the retention test.

The use of a consensus panel to define a level of agreement on a subject has been reported [22]. Correctly employed consensus strategies can provide a more justified and credible solution to a problem than other methods. However, the reliability and validity of the consensus rely on appropriately selecting the panel members, deciding on acceptable levels of agreement, obtaining professional support, and disseminating results. The panel members were chosen for their wealth of experience in teaching and treating patients in specialist restorative practice, and there was high internal agreement between the panel members.

The study found high levels of agreement between the DUs’ treatment plan answers and the consensus panel treatment plan answers. There was a significant difference between pre-DPI training test (control) and post-DPI training test (p < 0.001), suggesting that the DUs’ treatment planning decision skills improved after the DPI training. Moreover, there was no significant difference between the post-DPI training test and the retention test (p = 0.563), suggesting that the DUs retained their knowledge even after 6 weeks. This study demonstrated that the DPI was able to aid DUs in assessing the clinical scenarios through a systematic and holistic approach. However, even with the DPI training, some variations in treatment planning decisions were still present, especially if there were additional challenges in the clinical scenario. Variations in clinicians’ treatment planning decisions have been attributed to the ambiguity of the clinical data, variations in their interpretation, the presence of local factors as well as systemic diseases, and the possible complications of dental treatment [20].

When comparing the effect of DPI training on the treatment planning decisions made by both year 4 and year 5 DUs, both cohorts showed improvement from pre- to post-DPI training (p < 0.05) with no significant difference (p = 0.05) in between year 4 and year 5 DUs. This could be due to the highly similar clinical exposure and ability to make treatment planning decisions.

Participants’ confidence levels increased significantly (p < 0.05) following DPI training, and this increase was maintained during the retention test 6 weeks after the DPI training. The confidence level was assessed by using a self-reported confidence level scale questionnaire based on the ABC scale, which was first published as the Academic Confidence Scale. It is a psychometric means of assessing the confidence that undergraduate students have in their own anticipated study behaviors in relation to their degree program. The ABC scale can provide a general measure of a student’s confidence in undertaking their academic course. It has been shown to be valid and can be useful to teachers in understanding their students, enabling the design of more effective teaching sessions [23].

In our research, a 10-point Likert scale was chosen, as it offers more variance and a higher degree of measurement precision than a 5- or 7-point scale. A 10-point scale is favored as it provides a better opportunity to detect small changes and greater strength for the DUs to explain their point of view. It also helps to minimize leniency and the central tendency bias [24]. The study found no significant correlation between the DUs’ self-reported confidence and the treatment planning scores in the pre-DPI training test and post-DPI training test. The results of the current study are in agreement with a previous study and a systematic review on self-reported levels of competence in medical doctors [1525]. The systematic review concluded that clinicians have a limited ability to accurately self-report their level of competency. The ability of self-evaluation is specific to each individual and other influencing factors including their beliefs and values. It is crucial for a clinician to be confident in performing procedures with clinical uncertainty. Meanwhile, their confidence level should never be so high that they ignore the potential risk and harm that may be associated with the procedure and do not evaluate their own competency. Therefore, a clinician should be able to temper confidence with a knowledge of their personal limitations and weaknesses and have the ability to self-evaluate their own competence. This is the best way to help clinicians analyze their work practices and to promote reflection on performance [26].

Online-based teaching and learning are becoming a necessity for education around the world. The advantages of online-based teaching and learning include the ability to learn across nations, the availability of more opportunities for learning, and improved accessibility and flexibility for students to seek education [17]. However, online-based teaching and learning come with limitations, such as the need for students’ self-discipline and motivation for learning and limited interaction or discussion between educators and students. Even with these limitations, the benefits of online-based teaching and learning outweigh the drawbacks [16]. According to the results of our study, the DUs’ treatment planning decisions and their confidence levels both improved, highlighting the success of online-based teaching and learning, which concurred with a previous study [16].

Decision-making is undoubtedly one of the most important skills in the healthcare profession. Overtreatment may involve a more invasive procedure, whereas undertreatment may lead to incomplete resolution of the disease. Therefore, dentists are required to master the skill of treatment planning to avoid overtreatment and undertreatment. There are several methods to prevent overtreatment and undertreatment, such as by reflecting upon and discussing complicated cases to highlight issues in treatment planning that may not have been initially apparent and aid the clinician in providing practical and predictable treatment [27]. Other than that, a structural framework such as decision aids can provide guidance in treatment planning. Decision aids decrease decisional conflict related to feeling uninformed, leading to a positive effect on patient-clinician communication. Decision aids also allow dentists to play a more active role in decision-making and have more accurate risk perceptions [27].

The DPI serves as a decision guide that provides a structured format to allow dentists to assess the inter-related factors that should be taken into consideration during the dental treatment planning process, which includes a patient’s medical condition during the assessment of a case, therefore providing holistic patient-centered care. The index can also assist dentists in the decision-making process, rather than providing rigid guidelines that would be overly restrictive. The index improves dentist-patient communication, as the treatment plan can be discussed with the patient before treatment begins, and it enables better prediction and prognosis in order to manage the patient’s expectations for each and every unique case.

Although the current results displayed a promising outcome regarding the positive effects of DPI training using an online video on treatment planning skills and confidence level, a larger sample size would be preferred to ensure a better representation of the population.

CONCLUSION

DPI training using an online-based video improved the treatment planning skills and confidence levels of DUs in the decision-making process. Further large-scale multi-center studies will be needed to strengthen the validity of the results.

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