Calculus Detection Calibration Among

Dental Hygiene Faculty Members Utilizing

Dental Endoscopy: A Pilot Study
Brian B. Partido, MS, RDH; Archie A. Jones, DDS; Dana L. English, MS, RDH;
Carol A. Nguyen, MS, RDH; Mary E. Jacks, MS, RDH
Abstract: Dental and dental hygiene faculty members often do not provide consistent instruction in the clinical environment,
especially in tasks requiring clinical judgment. From previous efforts to calibrate faculty members in calculus detection us-
ing typodonts, researchers have suggested using human subjects and emerging technology to improve consistency in clinical
instruction. The purpose of this pilot study was to determine if a dental endoscopy-assisted training program would improve
intra- and interrater reliability of dental hygiene faculty members in calculus detection. Training included an ODU 11/12 explorer,
typodonts, and dental endoscopy. A convenience sample of six participants was recruited from the dental hygiene faculty at a
California community college, and a two-group randomized experimental design was utilized. Intra- and interrater reliability
was measured before and after calibration training. Pretest and posttest Kappa averages of all participants were compared using
repeated measures (split-plot) ANOVA to determine the effectiveness of the calibration training on intra- and interrater reliabil-
ity. The results showed that both kinds of reliability significantly improved for all participants and the training group improved
significantly in interrater reliability from pretest to posttest. Calibration training was beneficial to these dental hygiene faculty
members, especially those beginning with less than full agreement. This study suggests that calculus detection calibration training
utilizing dental endoscopy can effectively improve interrater reliability of dental and dental hygiene clinical educators. Future
studies should include human subjects, involve more participants at multiple locations, and determine whether improved rater
reliability can be sustained over time.
Mr. Partido was a graduate student in Dental Hygiene Division, Department of Periodontics, University of Texas Health Science
Center at San Antonio School of Dentistry at the time of this study; Dr. Jones is Professor, Department of Periodontics, Predoc-
toral Division, University of Texas Health Science Center at San Antonio School of Dentistry; Prof. English is Clinical Assistant
Professor, Dental Hygiene Division, Department of Periodontics, University of Texas Health Science Center at San Antonio
School of Dentistry; Prof. Nguyen is Assistant Professor, Dental Hygiene Division, Department of Periodontics, University of
Texas Health Science Center at San Antonio School of Dentistry; and Prof. Jacks is Associate Professor, Dental Hygiene Divi-
sion, Department of Periodontics, University of Texas Health Science Center at San Antonio School of Dentistry. Direct corre-
spondence to Mr. Brian Partido, PO Box 341068, Sacramento, CA 95834; 916-752-2905; partido@livemail.uthscsa.edu.
Keywords: dental hygiene education, dental hygiene faculty, calibration training, calculus detection, educational technology,
dental endoscopy, faculty development
Submitted for publication 4/23/14; accepted 7/14/14

D
ental and dental hygiene faculty members
often do not provide consistent instruc-
tion in the clinical environment. Previous
research has revealed inconsistencies in agreement
among faculty members due to variations in clinical
judgment.1-9 North American dental students iden-
tified inconsistent clinical feedback as one of the
major obstacles in achieving clinical competence.1
Although the impact of faculty variation on student
performance is yet unknown,6 inconsistencies in
clinical instruction may diminish students’ incentive
to learn, reduce student satisfaction, and ultimately
affect patient care. Calibration training can increase
consistency in clinical instruction among faculty
members. Training that involves realistic situations
and contexts comparable to practice provides the
most effective outcomes.10,11
Calibrating clinical faculty members can
promote standardized instruction in educational en-
vironments. Calibration training uses criteria-based
standards to evaluate students and to reproduce those
standards in different situations.8 A well-designed
calibration program includes a faculty-developed
clinical evaluation system for assessing student
performance; subsequent evaluation of the faculty
in regards to implementing the clinical evaluation
system; and evaluation of the outcomes of the calibra-
tion program in regards to learner competence.8,10,12
Mackenzie et al. described one such program that
provided opportunities in which faculty members
identified critical or unacceptable errors, repro-
duced those errors on typodonts or extracted teeth,
and shared those examples with colleagues.9 An-
other study found that faculty calibration resulted in

124 Journal of Dental Education  ■  Volume 79, Number 2

evaluating student performance within the program’s
acceptable range of the gold standard (accuracy); re-
peated consistent evaluations of student performance
(intrarater reliability); and similar evaluations of stu-
dent performance within an acceptable range (inter-
rater reliability).13 Other researchers have suggested
that programs require the calibration of faculty to
the gold standard using the mastery approach, which
mandates instructors to score within an acceptable
range of the gold standard prior to providing clinical
instruction.8,9 The mastery approach in those studies
was found to ensure a determined standard of rater
reliability in order to promote competent instructors
that provided consistent clinical instruction.
Many obstacles prevent effective outcomes of
periodic calibration training, and personal tendencies
arising from previous experiences have encumbered
calibration efforts. Calibration training has been
found to help minimize the influence of individual
philosophies and values of clinical instructors with
formative and summative evaluation.3,4,13 Overall,
calibration training in those studies promoted the ad-
vantages of consistent clinical instruction and mini-
mized the effects of instructional inconsistencies.
From the students’ perspective, clinical feed-
back has been perceived as more credible when the
faculty were trained with exercises that fostered
subject mastery.14 The credibility of instructors can
be compromised when instructor evaluations vary
with similar student performance. In two previous
studies, dental faculty members demonstrated low
levels of interrater agreement with other faculty
members and with dental students in interpretation
of radiographs, diagnosis, and treatment planning of
periodontal disease.5,6 These types of inconsistencies
can compromise the integrity of clinical instruction
by varying the level of competence, which can deter
students from learning.
Limited research exists that attempts to im-
prove intra- and interrater reliability among clinical
faculty members in regards to calculus detection.
Previous studies, which utilized typodonts with
simulated calculus in calibration training, did not
find improvement in reliability levels.15,16 Those
researchers acknowledged the unrealistic nature of
simulated calculus as compared to authentic calculus
and recommended that future studies involve human
subjects and/or emerging technology in calculus
detection. However, with human subjects, clinical
faculty members have been found to experience
difficulty teaching proficiency in calculus detection
due to the subjective nature of sensory and motor
February 2015  ■  Journal of Dental Education
nerve control with the explorer.17 In addition, a ret-
rospective evaluation of interrater reliability among
clinical instructors revealed low levels of agreement
when faculty members were evaluated for residual
calculus on human subjects after student scaling.15
Establishing a calibration training program that uti-
lizes realistic conditions and objective methods of
accurately detecting calculus remains a challenge.
In the clinical educational environment, in-
structors have relied on calibrating calculus detection
with a gold standard or that of most senior faculty
members when they used an explorer. However,
emerging technologies have shown promise in the
detection of calculus.18 Most of this technology, such
as the LED-based optical probe, objectively detected
root surface calculus within in vitro mediums of
blood and sodium chloride solution,19 but lacked
proven results in vivo periodontal conditions.18
However, dental endoscopy allows the clinician to
see within the actual periodontal pockets and assists
in the assessment, diagnosis, and treatment of peri-
odontal disease.
One study explored the effectiveness of
endoscopy-enhanced scaling and root planing (SRP)
versus the gold standard in periodontal treatment20
of traditional SRP. Researchers have found that the
dental endoscope maximized the removal of plaque,
calculus, and root surface endotoxin and minimized
the excessive removal of cementum,21-26 especiallyin
pockets >5 mm on single- and multi-rooted teeth.27
However, other studies have found no significant
differences with the dental endoscope that involved
5-8 mm pockets,28 multirooted teeth,29 and inexperi-
enced operators.27-30 In the assessment and diagnosis
of periodontal conditions, researchers found a direct
relationship between bleeding on probing and the
presence and amount of subgingival calculus.31,32 The
use of closed subgingival SRP aided by the dental
endoscope resulted in the elimination of histological
signs of inflammation.32 Despite this, no research has
been published that explores if dental endoscopy
enhances faculty calibration in the evaluation of
calculus detection.
The aim of this pilot study was to determine if
a training program utilizing dental endoscopy would
improve intra- and interrater reliability levels of den-
tal hygiene faculty members in calculus detection.
Training included an ODU 11/12 explorer, typodonts,
and dental endoscopy. The study was designed to
address the following two research questions: Will
a calibration training program utilizing dental en-
doscopy improve intrarater reliability among dental
125
 hygiene faculty members? Will a calibration train-
ing program utilizing dental endoscopy improve
interrater reliability among dental hygiene faculty
members?
Materials and Methods
This study received Institutional Review
Board approval from the University of Texas Health
Science Center at San Antonio (protocol number
HSC20140057E). The aim was to evaluate the effect
of calibration training utilizing typodonts and dental
endoscopy on intra- and interrater reliability, utilizing
a two-group randomized experimental design.
A convenience sample of six dental hygiene
faculty members at Sacramento City College were
assigned to control and training groups using adaptive
randomization, based on faculty employment status.
The participants were three full-time and three part-
time faculty members. These individuals possessed
many years of clinical dental hygiene experience and
had teaching experience ranging from less than a year
to over 20 years. Only one participant was a new
faculty member, having started clinical teaching dur-
ing the academic year of this study. At the informed
consent meeting, the principal investigator discussed
the study’s protocol and instructed participants to
refrain from discussing the study with other partici-
pants to minimize any threats to group assignment
and participant bias. Participants could voluntarily
participate or withdraw from the study at any time.
Upon agreement to adhere to the protocols, the
participants signed the informed consent statement.
Testing and training were performed using
four typodonts with the manufacturer’s key that
listed the locations of factory-manufactured sub-
gingival calculus (Kilgore model P15DP-TR56C,
Kilgore International, Inc., Coldwater, MI, USA).
Three typodonts were used exclusively for pre- and
posttesting, and one was reserved for training with
the dental endoscope. The amount of calculus on
specific teeth was modified to achieve a range of
surfaces containing subgingival calculus: typodont
Table 1. Testing and training protocol
Group Week 1 Week 2 Week 3 Week 4
Control Pretest No intervention No intervention Posttest
Training Pretest Calibration training Calibration training Posttest
(didactic) (clinical with dental endoscopy)
126
1 contained 10-16 surfaces, typodont 2 contained
17-24 surfaces, and typodont 3 contained 25-30
surfaces. The participants’ exploring during pretest
evaluations altered the quality of simulated calculus
due to variations in lateral pressure, stroke strength,
fulcrum position, and deposit location on the tooth
surface. Therefore, after the pretest evaluations,
individual teeth containing factory-manufactured
subgingival calculus replaced existing teeth, which
restored conditions for the posttest evaluations.
During the calibration training of the training
group, the principal investigator utilized the dental
endoscope to allow 24X-48X magnified visualization
of subgingival root surfaces. The endoscope explorer
retracted artificial tissues with the sheath and stabi-
lized the 0.99 mm optic fibers to capture images and
project a video representation of an approximately 3
mm area. A variety of endoscope-specific explorers
with different angulations provided optimal access
to all tooth surfaces. To promote visualization, the
water irrigation feature was not utilized.
In the pretest (week 1), all participants utilized
the ODU 11/12 explorer for calculus detection on
each of the three typodonts two times as a baseline
for intra- and interrater reliability levels (Table 1).
Each of the 27 teeth was divided into four surfaces,
totaling 117 surfaces per typodonts. The participants
evaluated surfaces for the presence or absence of
subgingival calculus and marked either yes (calculus
detected) or no (calculus not detected) on the answer
sheet designed by the principal investigator.
Training for the training group consisted of
two one-hour calibration sessions. The first session
involved didactic instruction and discussion (week
2) about various concepts in calibration, exploring
technique, exploring sequence, and dental endos-
copy. The second session involved individualized
instruction (week 3). Each participant first evalu-
ated for subgingival calculus with the ODU 11/12
explorer on a training typodont; immediately scored
his or her answers; and then reconciled errors with
visualization of the surfaces with the dental endo-
scope and physical re-detection with the explorer.
Participants achieved mastery when they scored a
Journal of Dental Education  ■  Volume 79, Number 2
minimum of 80% accuracy (mean score=87%, mean
Kappa=0.732) against the answer key. This score par-
alleled calibration training requirements for regional
clinical board examiners. In the posttest (week 4), all
participants (members of both the control and train-
ing groups) evaluated for calculus using the ODU
11/12 explorer on each of the three testing typodonts
two times to test for changes in intra- and interrater
reliability levels.
When analyzing the data, the principal investi-
gator assessed accuracy with the comparison of par-
ticipants’ responses against an endoscopy-enhanced
answer key. Intra- and interrater reliability levels
were calculated using Cohen’s Kappa coefficient
because it analyzed data in nominal scale and con-
sidered rater agreement due to chance.33-35 Intrarater
reliability compared attempt one against attempt
two, whereas interrater reliability compared each
attempt against the answer key. Kappa values ranged
from zero (no agreement) to 1 (perfect agreement).
Values from 0.41 to 0.60 were in moderate agree-
ment, values from 0.61 to 0.80 were considered in
full agreement, and values greater than 0.81 were in
perfect agreement.33-35
Pre-training and post-training Kappa averages
of all participants were compared to determine the
effectiveness of the calibration training on intra-
Figure 1. Statistical analysis in study
Note: Repeated measures (split-plot) ANOVA of mean Kappa averages was used to determine whether training improved self-agreement
and between-rater agreement from pretest to posttest. It was also used to test variances among the following: control against training
groups; typodont 1 against typodont 2 against typodont 3; pretest against all posttest; and attempt 1 against attempt 2.
February 2015  ■  Journal of Dental Education
and interrater reliability. Variances between sample
groups were evaluated using repeated measures
(split-plot) ANOVA of the Kappa averages between
the following groups: control against training groups,
typodont one against typodont two against typodont
three, and all pretest against all posttest Kappa values
(Figure 1).
Results
Table 2 shows mean Kappa averages, F-sta-
tistic, and p-values for the measured intrarater reli-
ability levels. The data suggested that participation
in the study improved intrarater reliability levels for
all six faculty members, but significantly more for
those who received training than those in the control
group (test 3). A significant difference was found
between pretest and posttest mean Kappa averages
(test 3, f=25.728, p<0.01). Post hoc paired-samples
t-tests determined the mean differences of the control
group’s pretest to posttest levels and the training
group’s pretest to posttest levels (test 3, control 0.228,
t=3.810, p<0.01; test 3, training 0.269, t=4.116,
p<0.01). Additional post hoc one-sample t-tests
compared the mean differences and found that the
mean Kappa averages of the training group increased
127
 Table 2. Intrarater reliability (self-agreement) tests of calculus detection
Pretest/ Mean Standard
Test C/T Group Posttest Typodont Kappa Average Error F-statistic p-value

1 C 0.694 0.042
T 0.603 0.045
2.133 0.153
2 1 0.626 0.062
2 0.669 0.050
3 0.651 0.056
0.153 0.860
3 All Pre 0.524 0.041
Post 0.772 0.026
25.728 <0.01
C Pre-Post 0.228 0.060 3.810 <0.01†
T Pre-Post 0.269 0.065 4.116 <0.01†
C/T Pre-Post mean differences 0.021 36.659 <0.01‡
4 C Pre 0.580 0.049
C Post 0.808 0.045
T Pre 0.468 0.062
T Post 0.737 0.023
0.177 0.681
C=control group, T=training group
†
Follow-up paired-samples t-tests between control group pretest to posttest and training group pretest to posttest revealed significant
results.
‡
Additional follow-up one-sample t-tests comparing mean differences revealed mean Kappa averages of training group increased signifi-
cantly more than mean Kappa averages of control group.
Note: Repeated measures (split-plot) ANOVA of mean Kappa averages was used to determine whether training improved self-agreement
(test 4) and to exclude confounding variables (test 1=all control against all training, test 2=typodont 1 against typodont 2 against ty-
podont 3, and test 3=all pretest against all posttest).

significantly more than the mean Kappa averages of
the control group (t=36.659, p<0.01). No significant
differences were found between control and training
groups when the intrarater reliability calculus detec-
tion scores were compared (test 1=control/training
groups and test 2=three typodonts). No significant
improvement was found between mean Kappa scores
of the training group against the control group from
pretest to posttest (test 4).
Table 3 shows the mean Kappa averages, F-
statistic, and p-values for the measured interrater
reliability levels. The data suggested that the training
program significantly improved interrater reliability
levels for participants who received training in com-
parison to those who did not receive training (test
5). No significant differences were found between
control and training groups when interrater reliability
calculus detection scores were compared (test 1=con-
trol/training groups, test 2=three typodonts, and test
4=two attempts). A significant difference was found
between pretest and posttest mean Kappa averages
(test 3, f=33.274, p<0.01). Post hoc paired samples
t-tests determined the mean differences of the control
group’s pretest to posttest and the training group’s
pretest to posttest (test 3, control -0.112, t=2.789,
p<0.01; test 3, training -0.256, t=5.874, p<0.01).
Additional post hoc one-sample t-tests of the mean
differences revealed the mean Kappa averages of the
training group increased significantly more than the
mean Kappa averages of the control group (t=11.333,
p<0.01). In addition, significant improvement was
found between mean Kappa scores of the training
group against the control group from pretest to post-
test (test 5, f=5.105, p<0.05).
Discussion
This pilot study sought to determine if a train-
ing program utilizing dental endoscopy would im-
prove intrarater reliability (self-agreement) and inter-
rater reliability (between-rater agreement) of dental
hygiene faculty members in calculus detection. The
small convenience sample functioned well for this
pilot study. Overall self-agreement and between-rater

128 Journal of Dental Education  ■  Volume 79, Number 2

Table 3. Interrater (between-rater) reliability tests of calculus detection
Pretest/ Mean Kappa Standard
Test C/T Group Posttest Typodont Attempt Average Error F-statistic p-value

1 C 0.721 0.022
T 0.664 0.033
2.047 0.157
2 1 0.657 0.038
2 0.717 0.032
3 0.704 0.033
0.820 0.445
3 All Pre 0.601 0.030
Post 0.784 0.015
33.274 <0.01
C Pre-Post 0.112 0.040 2.789 <0.01†
T Pre-Post 0.256 0.044 5.874 <0.01†
C/T Pre-Post mean differences 0.072 11.333 <0.01‡
4 1 0.672 0.028
2 0.713 0.028
1.079 0.302
5 C Pre 0.665 0.037
C Post 0.777 0.017
T Pre 0.536 0.043
T Post 0.792 0.025
5.105 <0.05
C=control group, T=training group
†
Follow-up paired-samples t-tests between control group’s pretest to posttest and training group’s pretest to posttest revealed significant
results.
‡
Additional follow-up one-sample t-tests comparing mean differences revealed mean Kappa averages of training group increased signifi-
cantly more than mean Kappa averages of control group.
Note: Repeated measures (split-plot) ANOVA of mean Kappa averages was used to determine whether training improved between-rater
agreement (test 5) and to exclude confounding variables (test 1=all control group against all training group, test 2=typodont 1 against
typodont 2 against typodont 3, test 3=all pretest against all posttest, and test 4=attempt 1 against attempt 2).

agreement levels improved for all participants, but
significantly more for those who received the training
(Table 2, test 3, and Table 3, test 3). The calibration
training with dental endoscopy resulted in significant
improvement in between-rater agreement (Table 3,
test 5) but not in self-agreement (Table 2, test 4)
when the training and control groups were compared.
Overall, self-agreement levels improved
significantly from pretest to posttest (Table 2, test
3) for participants in both the control and train-
ing groups. This result was not consistent with the
previous study by Garland and Newell, which also
measured the effect of calibration training on calculus
detection.16 In addition, the calibration training with
dental endoscopy in our study did not significantly
improve self-agreement levels for the training group
(Table 2, test 4). This result was consistent with the
Garland and Newell study.16 In that study, pretest
self-agreement levels started in the full agreement
range, which limited the potential for improvement.
However, in our study, the participants started in
the moderate agreement range (all=0.524, control
group=0.580, training group=0.468), which allowed
for greater improvements. The data thus supported
the benefit of calibration training for faculty members
with less than full agreement levels. In addition, the
data supported the value of calibration training to
improve rater agreement between newly hired and
experienced clinical faculty members.
Between-rater agreement levels significantly
improved after the calibration training with dental
endoscopy (Table 3, test 5). This result was not
consistent with the Garland and Newell study.16 As
with self-agreement levels, between-rater agreement
levels improved significantly overall from pretest
to posttest for participants in the control and train-
ing groups (Table 3, test 3). Again, this result was
not consistent with the previous study, in which the

February 2015  ■  Journal of Dental Education 129

 pretest between-rater agreement levels started in the
full agreement range and limited the potential for
improvement.16 In our study, the participants started
in the moderate to full agreement range (all=0.601,
control group=0.665, training group=0.536), which
allowed for greater potential for improvement.
Previous studies reported between-rater agreement
levels of 0.34015 and 0.780.16 The data in our study
supported the value of calibration training for faculty
members with less than full between-rater agree-
ment and reemphasized the value of the quality of
calibration training over the quantity. In our study,
the training consisted of two one-hour sessions, one
of which included individualized instruction with the
endoscope. Anecdotally, the faculty members in the
training group reported appreciating the opportunity
to confirm their discrepancies in calculus detection
and to self-assess personal detection errors.
A remarkable result was the finding that all
participants significantly improved in self-agreement
and between-rater agreement from pretest to posttest
(Table 2, test 3 and Table 3, test 3). Faculty employ-
ment status may have affected the pretest agreement
levels, which started in the moderate agreement
range. Part-time faculty members provided better
evaluations of periodontal procedures than full-time
faculty members in a previous study;4 however, no
previous study has measured differences in calcu-
lus detection rater agreement due to faculty status.
The learning effect (i.e., gradual improvement with
the repetition of a task)36 may help explain overall
improvement with all participants in our study. The
combination of the learning effect and training effect
may also explain why the training group improved
significantly more than the control group, which
was observed in previous calibration studies.8,13,37,38
Another influencing factor for improvement from
pretest to posttest was the pretest timing. The pretest,
administered one week prior to the start of the term,
was preceded by a one-month break between terms.
Levels of agreement may vary depending on the
amount of clinical dental hygiene performed external
to the academic environment. No previous studies
have measured levels of agreement at different times
during an academic term.
The limitations of this pilot study included the
simulated calculus, typodonts, and the production
of the endoscopy-enhanced answer key solely by
the principal investigator. In addition, the study was
performed in only one academic dental institution,
thus limiting its generalizability to other institutions.
130
Despite these limitations, this calibration study re-
sulted in significant improvements from pretest to
posttest in both self-agreement and between-rater
agreement levels (Table 2, test 3 and Table 3, test 3).
In addition, the calibration training with the dental
endoscope significantly improved between-rater
agreement levels from pretest to posttest (Table 3,
test 5).
Future studies to further the knowledge base
should include human subjects combined with the
emerging technology of endoscopy. The endoscopy-
enhanced subgingival calculus answer key would
reduce the subjective element of calculus detection
and provide a realistic nature of calculus detection
that is lacking when using typodonts. Since calculus
detection could have varied depending on faculty
employment status, whether part-time or full-time,4
additional research should investigate the effect of
faculty employment status on calculus detection.
Future studies should also conduct testing and train-
ing in the middle of academic terms to minimize the
effects of pretest timing outside of academic terms.
Although the mid-day timing of testing and training
improved convenience for the participants, anec-
dotally they mentioned they would have preferred
early morning sessions on non-academic days to
improve alertness, concentration, and tactile sensi-
tivity. The use of more participants from multiple
sites would help identify the potential benefits for
a variety of populations. Furthermore, the testing
of rater agreement levels at different times during
academic terms could help identify the need for
more regularly scheduled calibration training. Since
improved between-rater agreement occurred, future
studies should determine if the effects of calibration
training can be sustained over time.
Conclusion
This pilot study investigated the effect of
calibration training on dental hygiene faculty
members using the emerging technology of dental
endoscopy to enhance calculus detection. Changes
in self-agreement and between-rater agreement
measured the levels of improvement. Our findings
suggest that calibration training can be beneficial
to dental hygiene faculty members and possibly
dental faculty members as well, especially for those
beginning with less than full agreement. Calibra-
tion training can also be valuable in improving rater
agreement between newly hired and experienced
Journal of Dental Education  ■  Volume 79, Number 2
clinical faculty members. In addition, calculus detec-
tion calibration training utilizing dental endoscopy
can effectively improve between-rater agreement of
clinical educators.
Acknowledgments
The authors would like to thank John Kwan,
DDS (Perioscopy, Incorporated) for providing the
nPS perioscopy system and endoscope training used
for the clinical calibration session; Dean Marybeth
Buechner and Dean Jim Collins (Sacramento City
College) for their assistance with the research pro-
posal; Halsey Boyd, MSc (Sacramento City College)
for his expertise in statistical analysis; and the Sacra-
mento City College dental hygiene faculty members
for their continual commitment to education and their
participation in this research study.
Disclosure
The authors do not have any financial, econom-
ic, or professional conflicts of interests to disclose.
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Journal of Dental Education  ■  Volume 79, Number 2