The Effects of Mandatory Attendance on the Students’ Overall Performance in an Operative Dentistry Preclinical Course: A Retrospective Study

ABSTRACT

Purpose/Objectives

To evaluate the effects of mandatory attendance on the theoretical and practical grades of two consecutive classes in the Operative Dentistry II preclinical course at Tufts University School of Dental Medicine (TUSDM).

Methods

The theoretical and practical grades of students from two consecutive academic years were extracted and analyzed without any identifying information. For the theoretical portion, the final grade was used (45% midterm, 45% final exam, and 10% quizzes). For the practical component, the average of the three competency assessments was considered, along with performance on each competency separately. Data were statistically analyzed using the Kruskal–Wallis and Dunn tests (α = 0.05).

Results

Students in the year with mandatory attendance showed significantly higher performance in both theoretical and average practical grades (p < 0.001). The median (interquartile intervals) theoretical grade was 91.380 (86.957–95.205) in the non‐mandatory group and 93.825 (88.730–96.930) in the mandatory group. For the practical component, medians were 78.333 (73.333–83.333) and 82.5 (79.5–86.25), respectively. When competencies were analyzed individually, no statistically significant difference was found for the second and third procedures (p = 0.153 and 0.619), but the non‐mandatory group performed significantly better in the first competency (p = 0.003).

Conclusion

Within the conditions of this Operative Dentistry II preclinical course, mandatory attendance was associated with higher overall performance in both theoretical and practical assessments. However, when individual competencies were analyzed separately, results varied, suggesting that the impact of mandatory attendance may not be uniform across all skill areas.

1. Introduction

The role of mandatory attendance in preclinical dental education remains a topic of ongoing debate [1]. It has been proposed that structured, in‐person participation is essential for developing psychomotor skills, refining ergonomics, and mastering material manipulation, skills that are difficult to acquire without hands‐on practice and direct faculty feedback. Preclinical simulation sessions provide opportunities for immediate correction and deliberate practice, which are critical for competency before transitioning to patient care. Some studies suggest that attendance positively correlates with performance [2], reinforcing the idea that physical presence enhances learning outcomes. However, opposing views highlight that attendance alone does not guarantee improved skills or knowledge retention [3]. The increasing availability of digital learning tools, asynchronous training methods, and objective self‐assessment technologies challenge the necessity of compulsory presence, suggesting that motivation and learning environment quality play a greater role in student success [4, 5].

Dental education is uniquely challenging, as it combines didactic learning, preclinical training, and clinical exposure. In addition to the intellectual demands, students face high tuition costs [6] and professional expectations, making academic success a top priority [1]. Within dental curricula, preclinical courses serve as a critical transition between theory and patient care, allowing students to develop technical skills in a controlled environment. Operative dentistry preclinical courses, in particular, are often students’ first exposure to hands‐on procedures, requiring structured instruction on ergonomics, handpiece assembly, and material handling. First‐ and second‐year students must balance these courses alongside other didactic and preclinical commitments, while also adjusting to the demands of dental school.

Given these challenges, some students choose not to attend classes regularly, opting instead to watch recorded lectures and complete practical projects independently. While this approach may work for highly organized and self‐sufficient learners, others may struggle with time management, delayed project completion, and reduced faculty interaction, ultimately affecting both theoretical, and practical performance. This raises concerns about the role of mandatory attendance policies in fostering student success.

The COVID‐19 pandemic further complicated this discussion, significantly impacting dental education worldwide. Lockdowns forced a rapid transition from traditional face‐to‐face instruction to virtual and bi‐modal learning, where online lectures supplemented in‐person training. While this shift presented challenges, such as limited access to simulation labs and reduced clinical exposure, it also accelerated the adoption of digital learning tools and alternative teaching methodologies [7]. Some institutions responded by reinforcing mandatory attendance to compensate for lost hands‐on experience, ensure student participation, and maintain educational quality [1]. Conversely, others argued that remote learning successfully fostered critical thinking, problem‐solving, and clinical reasoning, questioning the necessity of strict attendance policies [1]. These contrasting perspectives highlight the ongoing debate on the role of mandatory attendance in preclinical education, particularly as dental schools continue to adapt in the post‐pandemic era.

At Tufts University School of Dental Medicine (TUSDM), the Operative Dentistry II preclinical course follows a structured curriculum designed to develop both theoretical knowledge and psychomotor skills necessary for restorative procedures. In addition, it provides a bridge between Operative Preclinical course and third‐year clinical experiences and introduces more advanced restorative procedures and esthetics. The course spans 4 months during the fall term and incorporates a combination of didactic instruction, hands‐on training, and competency‐based assessments. Each 3‐h session consists of a didactic lecture (typically 40 min), followed by practical application and faculty feedback, ensuring a student‐centered learning environment. Assessment in this course follows a multi‐component structure, comprising summative assessments (theory exams), competency‐based evaluations (practical assessments), and formative assessments (low‐stakes quizzes designed to reinforce understanding). In addition, students complete a series of restorative projects that require faculty sign‐off, reinforcing self‐directed learning, and time management. A more detailed description of the course structure and assessment methods is provided in the “Materials and Methods” section.

Despite extensive discussions on attendance policies in dental education, the relationship between attendance and academic performance remains unclear. While some studies suggest a positive correlation between attendance and student success, others find no significant impact. Moreover, student and faculty perspectives on attendance often differ, with some students perceiving lectures as unengaging or unnecessary. Rather than enforcing rigid attendance policies, some argue that institutions should focus on enhancing student motivation and adapting instructional methodologies to foster engagement [5, 8].

In light of this ongoing debate, this study aimed to assess the effects of mandatory attendance on both theory and practical grades of two consecutive classes of the Operative Dentistry II preclinical course at Tufts University School of Dental Medicine. The null hypothesis tested was that there would be no significant difference in student performance between the two cohorts.

2. Materials and Methods

This study was granted exempt status by the Tufts Health Sciences Institutional Review Board (Study #00006076).

2.1. Course Description

At TUSDM, second‐year students enrolled in the Operative Dentistry II preclinical course, a 2‐credit‐hour course (1 for the theory, 0.5 for the practical, and 0.5 for the projects) designed to develop both theoretical knowledge and psychomotor skills required for restorative procedures. The course lasted 4 months during the fall term and included a competency‐based curriculum focused on advanced restorative techniques and clinical‐based training.

Each 3‐h session consisted of a didactic lecture (typically 40 min), where course directors introduced a new topic and provided detailed procedural instructions, often supplemented by instructional videos. The remaining time was dedicated to hands‐on training, where students executed the assigned project and received real‐time faculty feedback. In addition, a low‐stakes, formative assessment (quiz) was administered to gauge students’ understanding of recently covered concepts. The course was structured into three main components, which are described in detail below, and can be also seen in Table 1.

TABLE 1.

Summary of Course Assessment Structure.

Component	Assessment type	Weight	Evaluation method
Theory	Summative	90% (45% midterm, 45% final)	Multiple‐choice exams
	Formative	10%	Weekly quizzes (participation‐based)
Practical	Summative	100%	Competency‐based assessments (three projects)
Projects	Competency‐based	Honors/pass/fail	Faculty sign‐off

2.1.1. Theory

The theoretical component assessed students’ cognitive knowledge and conceptual understanding of Operative Dentistry through summative and formative assessments.

Summative assessment—students’ final theoretical grade was determined by two exams: a midterm (45%), consisting of 30 multiple‐choice questions for the cohort with non‐mandatory attendance and 42 questions for the cohort with mandatory attendance, and a final exam (45%), with 40 questions for the non‐mandatory group and 45 questions for the mandatory group.

Formative assessment—each didactic session included a quiz (10% of the final grade), serving as a low‐stakes, formative assessment to reinforce recently taught concepts. These quizzes were graded based on participation and effort, rather than accuracy, and were designed to promote active learning and enhance knowledge retention.

Both exams and quizzes covered essential topics in Operative Dentistry and were aligned with the course learning objectives. Many exam questions were developed based on common challenges observed during the execution of preclinical projects, ensuring that assessments reflected both theoretical understanding and practical application.

2.1.2. Practical

The practical component assessed students’ psychomotor skills, procedural accuracy, and time management through three competency‐based evaluations: class II extensive composite restoration (Maxillary first molar, #14MO); class II amalgam restoration (Mandibular second premolar, #20MO); and composite veneer restoration (Maxillary central incisor, #9). To achieve honors in the practical component, students were required to score 90 or higher (out of 100) in all three competencies, which was the same for both cohorts.

Competency assessment Process—for each competency, a structured evaluation rubric was developed by the course directors, assessing the following criteria: anatomy and contour; proximal contact / proximal contour; marginal integrity / surface finish. After the predetermined time limit (75 min), students completed a self‐assessment form and exited the simulation lab. Faculty members from the Department of Comprehensive Care, who were calibrated for standardized grading, then conducted a double blinded assessment (faculty were unaware of the student's identity, and students did not know which faculty member assessed their work).

Grading system—students received a score of 0 to 90 points, distributed as follows: 30 points for anatomy and contour, 30 points for proximal contact/proximal contour, and 30 points for marginal integrity/surface finish. An additional 10 points were awarded based on time management, organization, and proper use of rubber dam isolation. Each criterion was graded using a competency‐based evaluation scale: Ideal Performance–30 points, Modification Needed–20–25 points, and Deficient Performance–0–15 points.

Remediation process—students who scored below 65 on a competency were required to undergo remediation, which included: A one‐on‐one meeting with course directors to identify areas for improvement; assignment of additional projects for skill refinement; and a reassessment following the same structured evaluation process.

Students who scored exactly 65 were also required to meet with course directors for targeted feedback and project assignments, although they were not required to repeat the competency assessment.

2.1.3. Projects

The project component was designed to reinforce self‐directed learning, procedural repetition, and faculty‐guided refinement. Students were required to complete 19 different projects, with each project needing to be repeated a specified number of times before faculty sign‐off.

Project Evaluation—each project was assessed using a competency‐based rating scale: Below Expectations, Meets Expectations, or Exceeds Expectations.

Submission Deadlines—project lists were collected on predetermined dates and all projects had to be completed and signed off by faculty.

Attendance requirement for honors—to qualify for honors in the project component, students had to attend at least 95% of all course sessions and submit all completed project lists by the deadlines. This was only applied to the class where attendance was made mandatory. In the cohort where attendance was not mandatory, honors were not awarded for the project portion.

2.2. Data Collection

This study involved a retrospective analysis of student performance in the Operative Dentistry II preclinical course to evaluate the impact of mandatory attendance on theoretical and practical performance. Data was collected from two consecutive cohorts.

Eligibility and data sources were as follows: All students enrolled in the Operative Dentistry II course during the two academic years under analysis were included. Final course grades and competency assessment scores were obtained from the institutional learning management system (Canvas). Only numerical grades were collected, with no identifying information (e.g., student names, ID numbers) accessed or stored.

For both the theoretical and practical components, final grades were analyzed. In addition, within the practical portion, individual competency scores for Class II composite restoration, class II amalgam restoration, and composite veneer restoration were assessed to determine whether attendance had a differential impact on specific skills.

2.3. Sample Size and Statistical Analysis

A convenience sample of up to 450 student records was used, based on the class sizes of the two cohorts under analysis. For each portion (theory and practical), the data (grades) were analyzed independently. Sigma Plot 15.0 software (Systat Sotware Inc., Chicago, IL, USA) was used for calculations. Normality and homoscedasticity of the data were checked with the Shapiro–Wilk and Brown–Forsythe tests, respectively. For the theory, data did not follow a normal distribution, whereas for the practical, data did not follow a homogeneous distribution. Hence, data were analyzed using Kruskal–Wallis and Dunn tests to assess the possible effect of mandatory attendance on the outcomes of the different assessments. The significance level was set at 0.05. A post hoc power analysis was conducted using estimated effect sizes derived from the observed differences in median grades and interquartile ranges. Although nonparametric tests (Kruskal–Wallis and Dunn) were used for the main analysis, power was estimated based on an equivalent two‐sample t‐test model. The statistical power was approximately 98% for the theoretical comparison and 100% for the practical comparison, indicating a high likelihood of detecting true differences between the cohorts. Power calculations were performed using the t‐test and Power function from the statsmodels package in Python (version 0.13.5).

3. Results

3.1. Theory

For that analysis, only the final grade (100%) was used for analysis. The data were not normal (Shapiro–Wilk p < 0.05). The data were then analyzed by Kruskal–Wallis One Way analysis of variance on ranks and Dunn test. The median and interquartile range of both groups (mandatory and non‐mandatory attendance) are presented in Table 2. There was a statistically significant difference between the two experimental groups. The group where the attendance was mandatory performed significantly better than the group where the attendance was only encouraged for the theoretical exams (p < 0.001).

TABLE 2.

Median and interquartile range of theory performance for both groups (mandatory and non‐mandatory attendance).

Group	N	Median	25%	75%
Non mandatory attendance	198	91.380 a	86.957	95.205
Mandatory attendance	204	93.825 b	88.730	96.930

^{a, b} denote differences among groups within time intervals (p ≤ 0.05).

3.2. Practical (Competencies)

For the practical portion, the mean of the three competencies was used for the statistical analysis, then a separate analysis was made for each one of the competencies. For the mean of the competencies’ grades, the data were normal (Shapiro–Wilk p = 0.270) but failed the equal variance test (Brown–Forsythe p < 0.05). The data were then analyzed by Kruskal–Wallis One Way analysis of variance on ranks and Dunn test. The median and interquartile range of both groups (mandatory and non‐mandatory attendance) are presented in Table 3. There was a statistically significant difference between the two experimental groups. The group where the attendance was mandatory performed significantly better than the group where the attendance was only encouraged for the competencies (p < 0.001).

TABLE 3.

Median and interquartile range of the mean of the three competencies for both groups (mandatory and non‐mandatory attendance).

Group	N	Median	25%	75%
Non‐mandatory attendance	197	78.333 a	73.333	83.333
Mandatory attendance	204	82.5 b	79.5	86.25

^{a, b} denote differences among groups within time intervals (p ≤ 0.05).

3.2.1. Competency I—Class II Extensive Composite Restoration

There was a statistically significant difference between the two experimental groups. The group where the attendance was not mandatory performed significantly better than the group where the attendance was made mandatory the competency on class II composite restoration (p = 0.003). The median and interquartile range of both groups (mandatory and non‐mandatory attendance) are presented in Table 4.

TABLE 4.

Median and interquartile range of the students’ performances at their competencies for both groups (mandatory and non‐mandatory attendance).

Group	N	Median (25%–75%) competency I	Median (25%–75%) competency II	Median (25%–75%) competency III
Non‐mandatory attendance	197	80 a (75–85)	75 (70–80)	80 (70–90)
Mandatory attendance	204	75 b (70–85)	75 (70–85)	80 (70–85)

^{a, b} under the Competency I column denote differences among groups within time intervals (p ≤ 0.05).

3.2.2. Competency II—Class II Amalgam Restoration

There was no statistically significant difference between the two experimental groups (p = 0.153). The median and interquartile range of both groups (mandatory and non‐mandatory attendance) are presented in Table 4.

3.2.3. Competency III—Composite Veneer Restoration

There was no statistically significant difference between the two experimental groups (p = 0.619). The median and interquartile range of both groups (mandatory and non‐mandatory attendance) are presented in Table 4.

4. Discussion

Based on the results of the present study, the null hypothesis that there would be no difference between the two cohorts was rejected. Statistically significant differences were observed in both theoretical grades and in the overall average of the practical competencies, with higher performance in the cohort where attendance was mandatory. However, when competencies were analyzed individually, results varied, and no consistent advantage was found across all procedures. It is important to note that the mandatory attendance policy was implemented as part of the course's standard structure, independent of this research. The present study merely analyzed its retrospective impact, without influencing or modifying the policy itself.

Consideration should be given to the fact that, for both portions of the course, the numerical difference between the two cohorts was relatively small. For the theory portion, both groups performed impressively well, with a median above 90, regardless of the attendance policy. This suggests that, even with mandatory attendance, the actual impact on theoretical grades was limited. One possible explanation is that lectures were recorded, allowing students to review the material and prepare for exams on their own time. In a previous study conducted at the same dental school, students reported that access to online resources in addition to live lectures was helpful, which corroborates our findings [4]. However, it has been reported that recording lectures may result in reduced attendance by 10%–33% [9]. In addition, it is important to note that the number of exam questions differed between the cohorts due to a recommendation from the school. However, the level of difficulty of the exams remained consistent. The close similarity in median performance between the two cohorts, despite reaching statistical significance, supports the notion that the exams were comparable in rigor.

For the competencies, the difference between the two cohorts was more noticeable than in the theoretical portion. The cohort with mandatory attendance presented a median score slightly above 80, while the non‐mandatory group remained below that threshold. This finding was not unexpected, since critical hand skills are developed during the course. During practical classes for the Operative courses at TUSDM, the instructor typically begins with a brief presentation on the topic at hand and then explains, in detail, the hands‐on project that the students will carry out that day. This explanation is augmented by a demonstration video highlighting the nuances of this project, offering tips to perform it more easily and accurately, as well as pointing out the most common mistakes frequently observed in this type of work. If the student completes the project right after the explanation, all this information will be readily accessible in their memory. Moreover, the student has direct access to the faculty to request feedback. This structure aims to improve performance as they continue attending the practice sessions. Opposingly, when students are not present in class for the explanation and need to complete the project on their own time, they are already behind and need to catch up. To do so, they tend to skip some steps to make their work easier, often resulting in suboptimal project execution. In addition, the lack of direct access to faculty for feedback leads them to rely on their peers' opinions, which are biased—either because they do not want to hurt their classmates’ feelings or because they are not competent to evaluate a project they are also working on. These dynamics could partially explain the differences in competency outcomes observed between cohorts. In fact, similar findings have been reported in other health professions education, such as pharmacy, where adherence to a mandatory attendance policy was associated with improved academic performance and a reduction in failing grades. This supports the notion that structured attendance requirements may play a role in promoting student success, particularly in rigorous, and skills‐based curricula [10].

By contrast, when analyzing the competencies separately, an interesting trend emerged: students in the non‐mandatory attendance group performed significantly better in the Class II extensive composite restoration competency. However, there were no significant differences between groups for the Class II amalgam and composite veneer competencies. Despite this, the mandatory attendance group showed higher overall competency scores when all three were averaged. This suggests that while mandatory attendance may not have benefited students equally across all procedures, it contributed to more consistent overall performance. One possible explanation is that students in the non‐mandatory group who skipped class may have been more confident or experienced in Class II extensive composite restorations, leading to better performance in that specific competency. Also, the number of students was different in both classes. In addition, self‐practice outside of structured class time may have played a role. However, when considering the broader impact of attendance, mandatory participation likely helped weaker students improve in other competencies, ultimately resulting in higher overall competency scores. As part of the course structure, students who fail a competency or achieve the minimum passing score (65%) were required to meet with the course directors for individualized support. During these meetings, the course directors assess whether their performance on the exam was an isolated occurrence or if they have an underlying difficulty that had not been previously identified. Through direct observation, course directors have noted that students tend to face different challenges. Those who struggle with the first competency are generally not the same students who struggle with the second. This observation suggests that the skills required to perform a composite resin restoration differ from those needed for an amalgam restoration, for example, which may partially explain the different outcomes observed when the three competencies were analyzed separately.

For the practical portion, in the cohort where attendance was mandatory, three students achieved honors, whereas in the cohort where attendance was not mandatory, only two students did. For the projects’ portion, in the cohort where attendance was mandatory, 128 students achieved honors, representing 62% of the class. While this is a high proportion, it was implemented as an incentive to reward students who consistently attended sessions and met all project deadlines. It should be emphasized, however, that honors criteria for the practical portion were identical across cohorts, and honors data—whether practical or projects—were not included in the statistical analyses or in the study conclusions, but were presented only to provide contextual information on course structure.

Although the project portion of the course was not included in the statistical analysis, since performance was based on meeting deadlines and completing all assigned projects to an acceptable standard, the authors considered it important to highlight some relevant observations. Completing these projects represents a key component of skill development and contributes, both directly and indirectly, to student preparation for the practical competency assessments. Therefore, even if not formally analyzed, student engagement with the projects may have played a meaningful role in shaping their overall practical performance. In that sense, for the project portion of the course, students received a list of projects that they needed to finish by a due date. Those projects needed to be graded and signed off by a faculty member. Students were required to complete more than one repetition for each exercise. Therefore, the ideal scenario would be for them to follow the course by performing the activity of the day and using the practice sessions after hours to complete the additional repetitions. However, due to the number of projects that they were required to finish and the signatures they must obtain from faculty, they often ended up focusing on these tasks and used class time to complete overdue projects.

Even though the course followed the same structure for both consecutive years, with mandatory attendance being the main difference, some factors should be taken into consideration as they may have contributed to the results of this study. One being the ratio of faculty/students. In the year when attendance was not mandatory, the simulation laboratory operated with fewer faculty members compared to the following year, when attendance became mandatory. That, in turn, might also have contributed to the fact that the students needed fewer check offs at the end of the course, once they had more access to faculty feedback. Another factor that differed between the 2 years was the structure of the project sheets. In the cohort where attendance was not mandatory, students received a single project sheet containing all assignments, which had to be completed and submitted by the end of the course. However, in order to take each competency assessment, students were required to have the corresponding project checked off on the day of the exam, ensuring at least some level of preparation for that specific procedure. In the cohort with mandatory attendance, the projects were divided into three separate sheets, each with a specific deadline. While this structure was intended to help students pace their work throughout the term, an analysis of the actual deadlines revealed that, for two of the three competencies, the project submission deadlines did not precede the assessment dates. Only for the second competency were students required to have the corresponding project signed off beforehand. That said, because attendance was mandatory in this second group, students were consistently present and likely working on their projects throughout the course. As a result, it is plausible that many of them obtained faculty signatures prior to the competencies, even if the official deadlines did not require it. Still, the actual influence of this structural change on student performance remains uncertain.

One must take into account as a limitation of this study that only the grades were taken into consideration in order to assess the effects of mandatory attendance. To fully understand this, demographic information like the age of the students for example should also have been considered. Furthermore, while grades are a valuable indicator of performance, the experience gained through class attendance, interaction with peers and faculty, and overall engagement also contribute significantly to student learning [11]. Conversely, TUSDM is the second largest dental school in the United States and has a uniquely diverse student body [12], so the results of this study could potentially help other dental schools worldwide, if they offer courses in a similar attendance pattern setting. This is a significant strength of this study. In addition, to the authors’ knowledge, no other study has compared two different cohorts of the same course to evaluate the impact of mandatory attendance. Previous literature has relied mainly on expert opinions or student and faculty surveys. Despite the methodological limitations of this study, and the fact that certain factors cannot be fully isolated, we believe these findings add valuable evidence to the ongoing discussion. Future studies are encouraged to replicate this analysis in other preclinical courses to better understand the broader impact of attendance policies, and to follow students longitudinally to assess whether these differences translate into improved performance in clinical activities.

While a statistically significant improvement in overall student performance was observed during the year in which attendance was mandatory, these results should be interpreted cautiously and within the specific context of this course. They do not necessarily support the universal enforcement of mandatory attendance in preclinical education. Learning is a highly individual process and large class sizes make it unrealistic—and perhaps even unfair—to evaluate all students using the same standard. While mandatory attendance may benefit less‐prepared students by providing structure and consistent access to faculty support, it can also limit the autonomy and motivation of more advanced or self‐directed learners, who may thrive under more flexible conditions. Moreover, requiring attendance from students who are not genuinely engaged can have unintended negative consequences, such as disrupting the learning environment for others. Instructors often face faculty shortages and increasing class sizes [13], and in such contexts, it may be more effective for educators to focus their efforts on students who actively seek feedback and support, rather than enforcing universal presence. Encouraging students to take ownership of their learning and come forward when they need guidance may not only promote self‐regulated learning but also allow faculty to use their time and expertise more meaningfully.

Many factors must be considered for good performance in a course. It is well known that students miss classes for various reasons, with motivation being the primary one [5]. In addition, factors such as early morning classes, exam preparation, and lecturers' weak presentation skills have also been cited by students [8]. Within the specific limitations of this Operative Dentistry II preclinical course, mandatory attendance made a difference in student performance. However, it is believed that keeping them motivated and eager to attend the course is what will truly make a lasting impact.

5. Conclusion

Within the context of this Operative Dentistry preclinical course, mandatory attendance appeared to be associated with higher overall student performance in both theoretical and practical components. However, when individual competencies were analyzed separately, results varied, suggesting that the impact of mandatory attendance may not be uniform across all skill areas. These findings should be interpreted cautiously, as institutional context and curricular design may influence outcomes.

Ethics Statement

This study was granted exempt status by the Tufts Health Sciences Institutional Review Board (Study #00006076).