Impact of Tooth Crownability Index on Decision-Making Skills of Undergraduate Students

Abstract

Objective

This article evaluates the impact of the tooth crownability index (TCI) on decision-making accuracy among undergraduate dental students.

Materials and Methods

Seventy-seven undergraduate dental students participated. In session one, students assessed 10 randomly presented case scenarios in four separate rooms. They assessed the crownability and rated periodontal, endodontic, and prosthodontic support as good, fair, or poor. In session two, the same cases were reassessed with access to a TCI. Student decisions from both sessions were compared with those of an expert panel. In the end, students identified which TCI factors influenced their decision-making.

Statistical Analysis

Descriptive statistics, paired t-tests, and McNemar's test were used to compare student decisions with and without TCI, with significance set at p < 0.05.

Results

Student decisions aligned significantly more with expert analysis when using TCI (78.7% vs. 60.0%, p = 0.014). Improved agreement was also observed for periodontal support (p = 0.017), endodontic status (p = 0.040), and prosthodontic support (p = 0.023) in the TCI session. Students identified prosthodontic factors as the most influential in improving their assessments.

Conclusion

The TCI significantly improved students' accuracy in assessing tooth crownability across diverse clinical scenarios.

 

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Keywords

decision-making - restorability - undergraduate - crownability - full coverage crown - prosthesis

Introduction

Clinical judgment in dentistry is inherently complex and highly dependent on professional experience, often resulting in practitioner variability. Cognitive biases and heuristics, shaped by individual education, clinical exposure, and confidence levels, further influence treatment decisions.[1] A clinician's perspective, skill, and psychological state can significantly affect patient outcomes.[1]

Effective clinical decision-making forms the cornerstone of evidence-based dental practice. Yet, many restorative decisions fall within “gray zones,” where evidence is limited, and treatment choices are subjective.[2] In these situations, patients rely heavily on the dentist's clinical acumen to select appropriate interventions that balance function, aesthetics, and prognosis, reinforcing the ethical responsibility of clinicians to safeguard patient well-being.[3]

Several structured approaches have been proposed to aid clinical decision-making regarding the prognosis and management of compromised teeth. Avila et al[4] introduced a color-coded decision-making chart to guide extraction versus retention decisions for structurally compromised teeth. Zitzmann et al's[5] predictive evaluation incorporated periodontal, endodontic, and prosthetic parameters. Dawood and Patel[6] developed an index based on treatment needs, introducing variable levels considering local and systemic patient contexts. While these models offer valuable guidance, they often focus on broader prognostic outcomes or lack a systematic integration of the key restorative parameters essential for assessing a tooth's crownability. In contrast, the tooth crownability index (TCI) consolidates periodontal, endodontic, and prosthodontic factors into a structured, factor-stage scoring framework, offering a comprehensive and objective tool designed to assess a tooth's readiness for full-coverage restoration.

In restorative dentistry, decision-making becomes particularly critical when determining whether to retain or extract a tooth or replace a defective restoration. Alarmingly, studies have shown that newly qualified dentists often display inadequate diagnostic and treatment planning skills, raising concerns about the effectiveness of undergraduate training in fostering sound clinical judgment.[7] [8] Many students struggle with these decisions and rely heavily on their supervisors for guidance.[9] Fresh graduates are expected to manage patients independently without constant supervision, so it is imperative to incorporate decision-support tools into undergraduate education to improve their clinical competence.[10]

Tooth restoration is fundamental to routine dental care; real-world scenarios often defy textbook solutions. For example, an endodontically treated tooth with significant structural loss but adequate periodontal support may be restorable. In contrast, the same tooth with insufficient periodontal support or lack of ferrule may be deemed nonrestorable.[5] Consequently, a comprehensive evaluation of periodontal, endodontic, and prosthodontic factors is essential when assessing tooth restorability.

The TCI[11] provides a systematic, objective framework for assessing a tooth's readiness for full-coverage restoration. It evaluates periodontal factors (mobility, probing depth, radiographic bone loss, furcation involvement/recession),[12] [13] endodontic factors (periapical lesions, endo-perio lesions, overall endodontic status),[14] and prosthodontic factors (remaining sound coronal tooth structure, biological width status, ferrule characteristics and location, unsupported-to-supported structure ratio).[15] Each factor is organized into a stage-based system, guiding clinicians through a structured assessment to generate a quantifiable crownability score. Unlike earlier decision-making tools that rely on broad heuristics or isolated parameters, the TCI integrates multidisciplinary criteria into a unified, user-friendly model, enhancing objectivity, reproducibility, and clinical teaching in restorative dentistry.

Despite its potential educational and clinical benefits, the effectiveness of TCI in supporting undergraduate students' decision-making has not yet been investigated. Therefore, this study aimed to evaluate the impact of the TCI on decision-making accuracy among undergraduate dental students.

 

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Materials and Methods

Study Design and Participants

Seventy-seven undergraduate dental students, comprising final-year students and interns, participated in this study. The study's objective and voluntary participation were clearly explained to all participants through a printed information sheet and consent form. Students were informed of their right to withdraw from the study at any stage and were assured of the confidentiality and anonymity of their responses. Data collection and management adhered to institutional protocols and were conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Standing Committee for Scientific Research - Jazan University (Reference No.: REC-45/05/880).

 

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Case Scenario Preparation

A panel of six senior specialists (prosthodontists, periodontists, and endodontists), each with over 15 years of clinical experience, developed 10 clinical case scenarios involving structurally compromised teeth requiring restorative intervention. Each case included a detailed clinical description, standardized photographs, and radiographs. The expert panel evaluated each case based on TCI factors and classified them as definitely crownable, fairly crownable, to be crowned with caution, or poor crownability. Additionally, periodontal support, endodontic status, and structural integrity were independently assessed and categorized as good, fair, or poor.

 

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Study Procedure

The study was conducted in two consecutive sessions in quiet seminar rooms as illustrated in [Fig. 1]. During the first session, participating students were randomly distributed across four similar lecture halls and seated individually to discourage any discussion among themselves. Each hall was overseen by an independent instructor who projected the case scenarios using Microsoft PowerPoint (Microsoft Office 365, Microsoft Corporation, United States) in a randomized order. Students were asked to assess the displayed case scenarios and opine based on their knowledge and the predefined criteria. Responses were recorded anonymously.

Fig. 1 Outline of student enrollment process and evaluation of decision-making with and without tooth crownability index (TCI).

Following a 20-minute break, students reconvened for the second session. They were given a printed TCI factor-stage chart.[11] The same case scenarios were then displayed again, and students were instructed to assess them by selecting appropriate factor-stage combinations. Crownability and supporting scores were calculated using an online TCI calculator ( https://restordent.in/tci/ ).[11] Finally, students were asked to identify the specific TCI factors most influencing their decision-making during the second session.

 

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Statistical Analysis

The sample size was calculated based on a within-subject comparison, assuming an expert agreement rate of 55% without TCI and 80% with TCI, targeting a clinically meaningful effect size of 25%, with 80% power and a 5% significance level. The required minimum sample size was determined to be 59 students. Data were analyzed using SPSS software (version 22.0, IBM Corp., Armonk, New York, United States). A test-retest design assessed the impact of TCI use. Descriptive statistics (frequencies and percentages) summarized student responses and agreement with the expert panel. Paired t-tests compared expert-match scores between sessions, and the McNemar test evaluated changes in paired categorical outcomes. Statistical significance was set at p < 0.05.

 

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Results

A total of 77 students (40 males and 37 females; mean age 24.42 ± 1.26 years) consented to participate in the study and completed both decision-making sessions regarding tooth crownability. [Table 1] summarizes the proportion of student responses that aligned with the expert panel's decisions across both sessions. Overall, students' decisions demonstrated greater concordance with expert assessments in session two, following the introduction of the TCI, across all case scenarios. A significant improvement in expert-match percentages was observed with the use of TCI across all measured parameters: crownability (p = 0.014), periodontal support (p = 0.017), structural support (p = 0.023), and endodontic status (p = 0.040) ([Table 2]). Further, a significant shift from incorrect (nonmatching) to correct (matching) decisions in the second session was seen as depicted in [Table 3], which shows the distribution of students based on whether their crownability assessments matched the expert panels'.

Table 1 Comparison of expert-match (%) between sessions one and two

Case no	Parameter	Session 1 Expert-match (%) (without TCI)	Session 2 Expert-match (%) (with TCI)	Difference (%)
1.	Crownability	80.52	88.31	7.79
	Periodontal support	77.92	89.61	11.69
	Endodontic status	79.22	83.12	3.90
	Structural support	83.12	90.91	7.79
2.	Crownability	83.12	94.81	11.69
	Periodontal support	83.12	93.51	10.39
	Endodontic status	77.92	93.51	15.58
	Structural support	81.82	96.10	14.29
3.	Crownability	72.73	81.82	9.09
	Periodontal support	74.03	81.82	7.79
	Endodontic status	71.43	80.52	9.09
	Structural support	74.03	83.12	9.09
4.	Crownability	76.62	84.42	7.79
	Periodontal support	76.62	83.12	6.49
	Endodontic status	72.73	81.82	9.09
	Structural support	76.62	84.42	7.79
5.	Crownability	31.17	59.74	28.57
	Periodontal support	35.06	61.04	25.97
	Endodontic status	41.56	66.23	24.68
	Structural support	38.96	55.84	16.88
6.	Crownability	42.86	71.43	28.57
	Periodontal support	44.16	71.43	27.27
	Endodontic status	50.65	75.32	24.68
	Structural support	38.96	68.83	29.87
7.	Crownability	37.66	66.23	28.57
	Periodontal support	36.36	61.04	24.68
	Endodontic status	53.25	61.04	7.79
	Structural support	35.06	62.34	27.27
8.	Crownability	46.75	74.03	27.27
	Periodontal support	45.45	74.03	28.57
	Endodontic status	55.84	68.83	12.99
	Structural support	42.86	71.43	28.57
9.	Crownability	62.34	80.52	18.18
	Periodontal support	61.04	79.22	18.18
	Endodontic status	71.43	72.73	1.30
	Structural support	59.74	79.22	19.48
10.	Crownability	66.23	85.71	19.48
	Periodontal support	62.34	77.92	15.58
	Endodontic status	75.32	80.52	5.19
	Structural support	64.94	84.42	19.48

Abbreviation: TCI, tooth crownability index.

Note: Case no. 1 and 3 “definitely crownable,” 2 and 4 “poor crownability,” 5, 6, and 7 “fairly crownable,” and 7, 8, and 10 “to be crowned with caution.”

Table 2 Comparison of cumulative expert-match (%) between assessments/decision-making without TCI and with TCI

Parameter	Assessment type	Mean	SD	95% CI		p-Value
				Lower	Upper
Crownability	Without TCI	60.00	18.97	−33.18	−4.22	0.014[a]
	With TCI	78.70	10.73
Periodontal support	Without TCI	59.61	18.19	−31.71	−3.62	0.017[a]
	With TCI	77.27	10.78
Endodontic status	Without TCI	64.94	13.31	−22.30	−0.56	0.040[a]
	With TCI	76.36	9.50
Structural support	Without TCI	59.61	19.17	−33.35	−2.75	0.023[a]
	With TCI	77.66	12.77

Abbreviations: CI, confidence interval; SD, standard deviation; TCI, tooth crownability index.

Note: Unpaired Student's t-test.

^a Significant if p ≤ 0.05.

Table 3 Distribution of students according to their expert-match status in both sessions

Case no.	Without TCI	With TCI		p-Value
		Matched	Not matched
1	Matched	62	0	0.031[a]
	Not matched	6	9
2	Matched	63	1	0.012[a]
	Not matched	10	3
3	Matched	56	0	0.016[a]
	Not matched	7	14
4	Matched	59	0	0.031[a]
	Not matched	6	12
5	Matched	24	0	< 0.001[a]
	Not matched	22	31
6	Matched	33	0	< 0.001[a]
	Not matched	22	22
7	Matched	29	0	< 0.001[a]
	Not matched	22	26
8	Matched	36	0	< 0.001[a]
	Not matched	21	20
9	Matched	48	0	< 0.001[a]
	Not matched	14	15
10	Matched	51	0	< 0.001[a]
	Not matched	15	11

Abbreviation: TCI, tooth crownability index.

Note: McNemar test.

^a Significant if p ≤ 0.05.

The improvement in expert-student match was most notable for cases assessed as “fairly crownable” and “to be crowned with caution,” where differences were higher compared with the “definitely crownable” and “poor crownability” categories ([Fig. 2]). [Fig. 3] details the specific TCI factors students perceived as most influential in their decision-making during the second session. The ferrule characteristics and location were cited by 65% of students, followed by biologic width status (51%) and the unsupported-to-supported tooth structure ratio (44%). In contrast, factors such as periapical lesion (3%), mobility (4%), and probing depth (6%) were the least frequently reported as impactful on their decisions.

Fig. 2 Case type differences (%) of activities as compared with expert choices.

Fig. 3 Perception of students regarding factors from activity two that aided in decision-making.

 

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Discussion

This study aimed to evaluate the impact of the TCI on the clinical decision-making abilities of undergraduate dental students. The findings demonstrated that implementing the TCI significantly improved the students' alignment with expert panel decisions across all assessed domains. A higher percentage of expert-matched responses was observed when students utilized the TCI, underscoring its utility as a structured, evidence-based tool that promotes systematic assessment in restorative dentistry.

The students reported that TCI facilitated an easier and more objective approach to case analysis by offering a comprehensive reference for factor-stage combinations. This led to a more scientific and methodical evaluation, mitigating overreliance on limited clinical experience. The study employed a repeated assessment model to robustly examine the TCI's impact, with a marked increase in expert-match scores following TCI integration. This reinforces TCI's role as an effective adjunct to enhance diagnostic accuracy at the undergraduate level.

The participants were final-year students and interns, who inherently presented with varying levels of knowledge. By conducting self-assessments and observing their progression post-TCI application, the study effectively captured the immediate benefits in decision-making skills. Conducting both sessions on the same day under standardized conditions minimized external confounders and improved the internal validity of the findings.

The expert panel's consensus was the method used here to compare the students' chosen options. However, this should be used only as a last resort when the literature suggests differing results. When forming the consensus panel, optimizing the advantages of having an informed group to evaluate the issue while mitigating the challenges inherent in collective decision-making is crucial.[16] The efficacy of a consensus panel can be enhanced by promoting diversity, ensuring that each member possesses varied clinical training, specialties, and experiences.[17] In this study, the panel members were selected based on their diverse academic backgrounds, extensive undergraduate expertise, and experience treating patients across various specialized clinics.

Notably, agreement levels between students and the expert panel improved consistently with TCI use across all case scenarios. Straightforward cases (e.g., case numbers 1, 2, 3, and 4) exhibited minimal difference between sessions (7.79–11.69%), reflecting students' inherent capability to resolve straightforward clinical decisions. However, for more ambiguous cases, where decision-making is typically more subjective, the TCI proved especially beneficial, where a greater difference (18.18–28.57%) was observed between sessions, supporting the TCI's role in clarifying complex restorative dilemmas.

Interestingly, in case number 5, the expert-match percentage nearly doubled in the second session compared with the first. Across all cases, significant improvements were observed in the periodontal, endodontic, and structural evaluations when students employed the TCI, with the most pronounced improvements seen in periodontal and structural assessments. In contrast, the endodontic evaluations demonstrated only minor improvements. These findings are consistent with van der Sanden et al[18] and Hamer et al,[19] who found that structured tools and clinical guidelines improve diagnostic precision and treatment planning among undergraduates.

The students perceived that several factors of TCI aided them in making a more objective assessment of case scenarios. All four structural factors were the most beneficial in evaluating crownability options across different cases. Students perceived ferrule height and location, biological width status, and unsupported-to-supported structure ratio as the most helpful. These factors provided concrete reference points, aligning with visible or measurable clinical indicators in the case scenarios. In contrast, periodontal factors such as probing depth and mobility, though critical, were less frequently utilized by students, likely due to a lack of tactile feedback in simulated cases or insufficient emphasis during preclinical training. Notably, endodontic assessment showed the least variation between sessions, suggesting that students were more confident in interpreting periapical pathology and pulp status, possibly due to better theoretical grounding. This highlights the need to strengthen interdisciplinary teaching that integrates these domains within clinical judgment frameworks.

Despite the incorporation of TCI in decision-making, variability in decisions persisted. The capacity of dental professionals to accurately identify conditions relies on several factors, including their competence, experience, and critical thinking abilities.[20] [21] Novice practitioners demonstrated deficiencies in foundational education about the management of carious lesions, which resulted in overtreatment.[22] Also, the diagnosis and the treatment choices for endodontic diseases differed based on the dental specialty training of the practitioner.[23] Considerable bias in clinical decision-making has been observed among dental practitioners, attributed to human memory and judgment limitations. Therefore, diagnostic tools must be integrated to assist doctors in enhancing clinical judgment and expertise,[24] which aid in analyzing and discussing complex treatment planning cases and can effectively highlight underlying challenges that may not have been immediately apparent. This process facilitates a more comprehensive understanding of treatment considerations, enabling clinicians to develop well-structured and pragmatic treatment strategies.[25]

Such tools, like the TCI, serve as valuable adjuncts in treatment planning, helping to deconstruct complex cases and highlight potential oversights.[25] Experts differ from novice clinicians in knowledge and the organization of cognitive processes that influence decision-making.[26] [27] Experienced dentists are adept at synthesizing clinical reasoning, patient factors, and past experiences to formulate more accurate treatment plans. The TCI, grounded in this expert knowledge, allows for a systematic appraisal of crownability, offering students a framework to deliver well-justified, patient-centered treatment proposals. Moreover, by quantifying crownability, the TCI facilitates transparent discussions with patients, aiding in setting realistic expectations.

The study design incorporated several methodological strengths. Randomization of students across lecture halls and case sequences minimized order effects and cognitive fatigue. Conducting both assessment sessions within the same day further reduced external influences such as information decay or peer discussions. These measures collectively bolstered the study's internal validity. However, while objective outcomes were prioritized, subjective evaluations regarding students' confidence or perceived decision-making improvement were not explored. Future research should address these perspectives to understand the impact of TCI on education comprehensively.

While the results suggest that the TCI significantly improved students' decision-making, the possibility of a reassessment effect cannot be entirely ruled out since the students reviewed the same cases in the second session. Although the sequence was randomized to reduce recall bias,[28] and interaction was restricted, increased familiarity with the cases may have played a role in the altered performance. Additionally, the absence of a control group reassessing the same cases without TCI limits the ability to isolate the TCI's unique contribution. Future studies incorporating a parallel control group are warranted to more definitively assess the standalone impact of TCI on decision-making.

Additionally, while this study demonstrated the short-term benefits of TCI use, long-term follow-up in clinical settings is needed to validate whether these improvements translate to sustainable clinical competency. Integrating tools like the TCI within undergraduate curricula could serve as a bridge between theoretical education and clinical application, fostering the development of critical diagnostic and treatment planning skills.[29] [30]

 

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Conclusion

In conclusion, this study highlights the TCI as a promising tool to enhance clinical decision-making among dental students. It systematically guides learners through complex diagnostic processes, improving alignment with expert assessments and potentially contributing to better patient care outcomes.

 

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Conflict of Interest

None declared.

Acknowledgment

None.

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Publication History

Article published online:
25 July 2025