發展臨床前根管治療技能之評估表

Abstract

欲得到良好的根管治療預後，在於醫師對於牙髓疾病有正確的診斷、治療計畫的擬定、以及良好的根管治療操作。在我國的牙髓病學教育中，老師藉由學生在自然牙或人造牙齒操作的過程表現，來評估學生根管治療技能的學習表現。在我國根管治療技能的學習大致分為三個階段：實驗課階段、臨床前階段與臨床階段。實驗課與臨床前階段的訓練材料，以口外牙（自然牙、塑膠牙）為主；而臨床的階段則以實際在病人口內的患齒中操作。因此，臨床前的口外牙根管治療技能操作的訓練是非常重要的，其銜接了實驗課的訓練以及未來即將面對病人的根管治療。然而，目前國內外的牙醫學教育中，對於臨床前的根管治療技能評估而言，尚未有一個可以簡便、快速、在有限時間內適用於老師與學生、並且涵蓋重要步驟的臨床前口外牙根管治療學習歷程評估表。 因此，本研究嘗試以五個步驟發展一個適合於「臨床前根管治療技能」、涵蓋全面、語意清晰、且對每個項目的重要性給予不同權重分配的評估表，以減少學員學習的摸索期並加快學習效率。以期提供給臨床前學生與老師做為臨床前根管治療技能之學習表現評估。 這五個步驟如下：（1）步驟一：整合了已發表的期刊文獻、教科書、此領域專家的知識與經驗擬定評估表的草稿。（2）步驟二：並經由三回合的修正式德菲法（modified Delphi method）達到專家的初步共識的評估表，使用敘述統計判別項目的重要且適合做為評估，以及魏式檢定判別前後回合專家的反應意見有無差異。（3）步驟三：再由三位專家以步驟二達成共識之評估表進行前導測，並對於評估表提出修正建議。（4）步驟四：再一次的以修正式德菲法，並使用敘述統計確認修正後的評估表達成專家共識。（5）步驟五：最後專家依照每個項目的重要程度給予不同的權重，並以此評估表藉由實際測試學生的口外牙，並以Cronbach's alpha作為評估表的內部一致性檢定、以肯德爾和諧係數（Kendall's coefficient of concordance）作為評估者間一致性檢定。另外本研究發展之評估表為邀請臨床教育經驗豐富三位專家學者，並參考國內外相關文獻學者提出之評估項目、指引及教課書籍，以界定與設計作為本研究評估表之初稿題項，此評估表並經過另外五位專家的意見共識而形成，因此具有相當程度的內容效度（content validity）。 本「臨床前根管治療技能評估表」最後確定了15個評估項目以及相關說明與權重；在於內部一致性Cronbach's alpha值為0.610，為中等信度；此信度符合於此評估表的設計目的、使用方式、環境與時機。而各題項之評估者間一致性肯德爾和諧係數顯著性之 p值皆小於0.05，即三位評估者的評分間有顯著相關，且評分結果頗為一致。並且修正式德菲法所達成的專家共識，其結果來是自群體專家的意見，比單一的個人決定更為有效；以及修正式德菲法是以連續回合達成共識的方式，使專家們有機會審查和判斷評估表的適當性。因此由修正式德菲法所達成的專家共識，本身就已經具有足夠的內容效度。 因此，本研究以五個步驟發展適合於「臨床前根管治療技能」、涵蓋全面、語意清晰、操作簡便、可近性佳的評估表；以期提供給臨床前學生與老師做為臨床前根管治療技能之學習表現評估。

To obtain a good root canal treatment prognosis, the doctor has a correct diagnosis of the pulp disease, an appropriate treatment plan, and a high-quality root canal treatment. In our country’s endodontics education, teachers evaluate students’ performance in root canal treatment technique learning by assessing students’ root canal treatment technique performance in natural or artificial teeth. The learning of root canal therapy techniques in my country can be roughly divided into three stages: undergraduate laboratory course stage, pre-clinical stage, and clinical stage. The training materials for the undergraduate laboratory course and the pre-clinical stage are mainly natural teeth and artificial teeth; while in the clinical stage, the actual root canal treatment is performed on the affected teeth of the patient. Therefore, the pre-clinical training of the root canal treatment in extraoral teeth is particularly important, which connects the training of the undergraduate laboratory course and the root canal treatment in patients. However, in our country and abroad, there is no pre-clinical evaluation checklist that can be simple, fast, suitable for teachers and students in a limited time, and covers important key steps for pre-clinical root canal treatment technical in extraoral teeth. Therefore, our research applied an integrative approach for designing checklists that evaluate pre-clinical root canal therapy technique performance. The approach consisted of five predefined steps. Step1. Based on the integration of relevant literature, guild lines, textbooks, and their clinical experience, three endodontic specialists with many years of clinical teaching of endodontic treatment drafted a preliminary checklist. Step2. After three rounds of the modified Delphi method, another five experts reached a preliminary consensus on the evaluation checklist. And we use descriptive statistics to determine the importance and suitability of the items as an evaluation, and we also use the Wilcoxon signed-rank test to determine whether there is a difference in the opinions of experts before and after the round. Stpe3. The three experts in step one will use the checklist reached a consensus in step two to conduct a pilot test and propose amendments to the evaluation checklist. Step4. To ensure the changes made after pilot testing were valid, the checklist was submitted to an additional modified Delphi review round. Step5. Finally, experts give different weights according to the importance of each item, and use Cronbach's alpha as the internal consistency reliability, and Kendall's coefficient of concordance is used for inter-rater reliability. This pre-clinical root canal treatment technique checklist was finally identified 15 evaluation key items and related descriptions and weights. The internal consistency reliability Cronbach's alpha value is 0.610, which is medium reliability; and this reliability is in line with the design purpose of this evaluation checklist. The p-value of Kendall's coefficient of concordance significance of the inter-rater reliability of each item is all less than 0.05; that is the three evaluators are significantly correlated and quite consistent. The expert consensus reached by the modified Delphi method is based on the opinions of group experts, which is more effective than a single individual decision; and the modified Delphi method is a way of reaching consensus in consecutive rounds, allowing experts to review and judge the appropriateness of the checklist. Therefore, the expert consensus reached by the modified Delphi method itself has sufficient content validity. Therefore, our study integrates published evidence and the knowledge of domain experts and uses five steps to develop a checklist for evaluating pre-clinical root canal treatment techniques, which is comprehensive coverage, clear semantics, easy operation, and accessibility; in order to provide preclinical students and teachers as preclinical root canal treatment technique learning performance evaluation.