Clinical Judgement And Decision Making In Endodontics

Clinical judgement in endodontics consists of much more than diagnosis and treatment planning for the affected tooth. The issues involved in clinical judgement and decision making can be summarised by three questions:

• 1 Is endodontic treatment appropriate for the patient? Endodontic treatment should be undertaken only as part of an agreed, comprehensive treatment plan that takes into account patient concerns as well as objective clinical findings.
• 2 How difficult is the endodontic treatment? The difficulty of the case should be balanced with the skill and experience of the dentist, in deciding whether to manage the case in general practice or to refer the patient to an endodontist. The use of a standard form for assessing the difficulty of each endodontic case will aid in consistent, systematic assessment of patients. An example of such a form is provided.
• 3 What is the prognosis for the tooth? The outcome of endodontic treatment depends not only on the endodontic treatment but on other factors such as restorability and periodontal status. The prognosis will be compromised by procedural problems and by restorative and periodontal factors.

In all but routine cases, the steps involved in decision making may be more complex and less easily resolved than the practical clinical aspects of endodontic therapy.     

Pre-clinical endodontics: a survey amongst German dental schools

Aim To evaluate the state and level of pre‐clinical endodontic education in German dental schools and to evaluate differences with regard to intensity and extent of teaching, time devoted to teaching pre‐clinical endodontics, personnel resources in teaching and technical equipment. Methodology Twenty‐eight questionnaires were e‐mailed to those in charge of pre‐clinical endodontic education in German dental schools. The extent of education, the student–teacher ratio, the teaching content as well as the application of teaching materials and technologies were asked. If, after 4 weeks, no response had been received, the questionnaire was sent out by e‐mail again. In the absence of a reply, a phone call was made to the corresponding university to conduct the survey by phone. Results With feedback from 27 of 28 dental schools, the response rate was 96%. Pre‐clinical endodontic education at German universities varied considerably. Theory classes ranged from 5 to 30 h (13.3 h mean), practical classes from 12.5 to 60 h (45.4 h mean). The student to staff ratio varied between 9 : 1 and 30 : 1 (16 : 1 mean). Forty‐eight per cent of the universities had a specialist in endodontics or a teacher with a special interest. A dental microscope was available for pre‐clinical teaching purposes in 38% of the universities. The majority (63%) of universities taught root canal preparation with rotary nickel titanium instruments. Conclusion Pre‐clinical endodontic education varied considerably between German universities because of differences in programme design, staff and course content.     

Setting up an MSc programme in endodontics

The course has been designed to provide a suitable foundation for academic and general practice careers. Emphasis has been placed on developing diagnostic and practical skills. Students are encouraged to review their clinical practice critically in the light of recent advances in knowledge. The course begins with an intensive period of lectures and seminars covering general aspects of endodontics, and is generously supplemented by practical demonstrations and classes on a variety of procedures performed on laboratory models. The course continues with lectures and seminars designed to stimulate group discussion. These are complemented by supervised clinical sessions encompassing assessment, planning and treatment of a comprehensive range of conventional and surgical endodontic problems. The syllabus includes relevant basic sciences, pathology, differential diagnosis, pharmacology and therapeutics. The biological basis for endodontics is stressed and covers the following: maintenance of pulp vitality; effects of pulp capping pulpotomy and pulpectomy; the management and treatment of traumatic injuries to teeth; the management of medically compromised patients; the effect of various methods of instrumentation of root canals; radiology; restorative treatment of the endodontically treated tooth; the interface between endodontics and periodontics, prosthetics or orthodontics. Each student is required to undertake a research project and write a report.     

Attitudes of final‐year dental students to bleaching of vital and non‐vital teeth in Cardiff,Cork, and Malmö

Summary The aim of this study was to determine attitudes of final‐year dental students in Cardiff, Cork and Malmö towards tooth whitening. Following receipt of ethical approval, pre‐piloted questionnaires were distributed to final‐year dental students in Cork, Cardiff, and Malmö as close as possible to graduation. The questionnaire sought information relating to various opinions and attitudes towards the use of bleaching techniques including safety of bleaching, confidence in the provision of bleaching, recommendations to patients, teaching received, awareness of restrictions on the use of bleaching products and management of simulated clinical scenarios. Eighty three per cent (n = 116) of questionnaires were returned. Cork dental students had the most didactic teaching (2‐h vital, 1‐h non‐vital bleaching) compared to Cardiff or Malmö students (0 h each). More Cork students regarded bleaching as safe (76%, n = 28) than Cardiff (70%, n = 32) or Malmö (36%, n = 12) students. More than 50% of Cork students feel they know enough about bleaching to provide it in practice, significantly more than Cardiff (<25%) or Malmö (<25%) students. The majority of students would provide vital bleaching after qualification (100% (n = 37) Cork; 82% (n = 27) Malmö; 76% (n = 35) Cardiff). In simulated clinical scenarios, more Cork students would propose bleaching treatments (89%n = 33) than Malmö (64%n = 21) or Cardiff (48%n = 22) students. Variations exist in the attitudes and approaches of three European dental schools towards bleaching. Dental students need to be best prepared to meet the needs of their future patients.     

Agreement between faculty member assessments and student self‐assessments in a preclinical endodontic programme

This study aimed to evaluate the agreement between faculty member assessments and student self‐assessments regarding the latter's performance in a preclinical endodontic course. The data were collected from 30 undergraduate dental students enrolled in a preclinical endodontic course at Taibah University in Saudi Arabia during 2017–2018 academic year. One course coordinator calibrated the grading method and distributed it to all staff and students. Students were asked to appraise their own performance of a root canal treatment for a tooth with a single canal. After the student self‐assessments, two staff members also graded student performance using the same grading scale. The assessment agreement was compared between student and faculty evaluations using a Wilcoxon signed‐rank test with a 0.05 significance level. There was a significant difference (P < 0.05) between student and staff member assessment scores. Student scores were lower and had a weak reliability compared to those of staff members.     

Attitudes of some European dental undergraduate students to the placement of direct restorative materials in posterior teeth

Summary The aim of this article was to report on the attitudes, opinions and confidences of final year dental students in three European schools towards the restoration of posterior teeth and in particular towards the use of amalgam and resin composite. One hundred and twenty‐eight pre‐piloted questionnaires were distributed to final year dental students in Cardiff, Dublin and Malmö. The questionnaire sought information relating to various opinions and attitudes towards the use of amalgam and resin composite in posterior teeth. Information was returned anonymously. Ninety‐one completed questionnaires were returned (response rate = 71%; Cardiff: n = 40, Dublin: n = 24, Malmö: n = 27). Ninety‐three per cent of Malmö students (n = 24), 67% of Dublin students (n = 16) and 60% of Cardiff students (n = 24) reported that they feel confident when placing posterior resin composites. One hundred per cent of Malmö students (n = 27), 75% of Cardiff students (n = 30) and 33% of Dublin students (n = 8) would prefer to have a resin composite rather than amalgam, placed in one of their own posterior teeth. Eighty‐five per cent of Malmö students (n = 23), 30% of Cardiff students (n = 12) and 25% of Dublin students (n = 6) perceive amalgam as being harmful to the environment. For the restoration of a posterior tooth in a pregnant female, 44% of students (n = 40) would place a resin composite restoration, and 7% (n = 6) would place an amalgam restoration, while 32% (n = 29) would place a temporary restoration. Students at Malmö report that they place more posterior resin composites and have greater confidence at placing posterior resin composites than students at Cardiff or Dublin. There was confusion relating to the choice of restorative materials for pregnant females. Large variations in restorative strategies among graduates must be considered as dental professionals can practice in all countries within the European Union.     

Evaluation of student and faculty perceptions of the PBL curriculum at two dental schools from a student perspective: a cross-sectional survey

Abstract Problem‐based learning (PBL) research has primarily highlighted issues related to medical education and less evaluation has been reported from the field of dental education. Furthermore, literature reports tend to focus mainly on PBL from a pedagogic and curriculum constructional view and up to this date, studies from a student perspective are lacking. The aim of this study was to approach the evaluation of student and staff perceptions of PBL curricula from a student perspective at two separate schools: the Faculty of Odontology at the University of Malmö, Sweden and the dental school of the University of Southern California, School of Dentistry (USCSD), Los Angeles, CA, USA. The study was initiated and conducted by two of the authors, at the time senior students at the Faculty of Odontology in Malmö, Sweden. The study was comprised of a literature search, a 2 week field trip to USCSD, USA, survey distribution to students and faculty in both schools, analysis of the data and a written report for oral defence. The results from the survey were intended to provide feedback on student and faculty perceptions regarding the PBL curriculum. The results indicate a general student and faculty satisfaction with the PBL curriculum. Perhaps, surprisingly their perceptions did not differ significantly despite differences in geography, culture and implementation of PBL pedagogy.     

Apexogenesis after initial root canal treatment of an immature maxillary incisor – a case report

Aim To present a case where a traumatized, immature tooth still showed capacity for continued root development and apexogenesis after root canal treatment was initiated based on an inaccurate pulpal diagnosis. Summary Traumatic dental injuries may result in endodontic complications. Treatment strategies for traumatized, immature teeth should aim at preserving pulp vitality to ensure further root development and tooth maturation. A 9‐year‐old boy, who had suffered a concussion injury to the maxillary anterior teeth, was referred after endodontic treatment was initiated in tooth 21 one week earlier. The tooth had incomplete root length, thin dentinal walls and a wide open apex. The pulp chamber had been accessed, and the pulp canal instrumented to size 100. According to the referral, bleeding from the root made it difficult to fill the root canal with calcium hydroxide. No radiographic signs of apical breakdown were recorded. Based on radiographic and clinical findings, a conservative treatment approach was followed to allow continued root development. Follow‐up with radiographic examination every 3rd month was performed for 15 months. Continued root formation with apical closure was recorded. In the cervical area, a hard tissue barrier developed, which was sealed with white mineral trioxide aggregate (MTA). Bonded composite was used to seal the access cavity. At the final 2 years follow‐up, the tooth showed further root development and was free from symptoms. Key learning points

• ? Endodontic treatment of immature teeth may result in a poor long‐term prognosis.
• ? The pulp of immature teeth has a significant repair potential as long as infection is prevented.
• ? Treatment strategies of traumatized, immature permanent teeth should aim at preserving pulp vitality to secure further root development and tooth maturation.
• ? Radiographic interpretation of the periapical area of immature teeth may be confused by the un‐mineralized radiolucent zone surrounding the dental papilla.

     

Ridge preservation in cases requiring tooth extraction during endodontic surgery: a case report

Aim To provide a treatment option to endodontists performing surgery that will enhance ridge preservation when tooth extraction is required. Summary A 47‐year‐old woman was referred to an endodontic practice for apical root‐end resection of tooth 22 because of refractory periradicular disease. Radiographic examination revealed a large periradicular lesion, 5 mm in diameter and a root‐end filling at the root apex. The treatment plan included exploratory surgery and apical root‐end resection. A vertical root fracture was diagnosed and the decision was made to extract the tooth. The socket was grafted with a cancellous bovine bone and covered with a resorbable collagen membrane. Follow‐up examination revealed favourable bone healing with formation of a new cortical plate and the preservation of soft tissue width and height in the aesthetic area. Key learning points

• • The principles of guided bone regeneration.
• • Preserving or reconstructing the extraction socket.
• • Enhances the ability to restore function and provide aesthetically pleasing restorations to patients without violating the predictability and function of the prostheses.

     

Questionable effect of lavage for treatment of painful jaw movements at disc displacement without reduction: a 3‐year randomised controlled follow‐up

The present randomised controlled study compared the 3‐year outcome of local anaesthetics with anaesthetics and lavage in patients suffering from painful temporomandibular joint (TMJ) locking. The study included 45 patients referred for treatment of temporomandibular disorders (TMD) to the Department of Orofacial Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden. All patients received a history questionnaire and clinical examination according to the Research Diagnostic Criteria for TMD, panoramic radiographs and magnetic resonance imaging at baseline. Twenty‐five patients were randomised to anaesthetics alone and 20 patients to anaesthetics and lavage. Three years after treatment, we sent the 37 patients who were available for follow‐up a questionnaire that evaluated pain intensity, physical and emotional functioning, and global improvement. Thirty‐four patients responded. The primary outcome was defined as ≥ 30% pain relief. In an intention‐to‐treat analysis, 28 of 45 patients (62%) reported ≥ 30% pain relief at the follow‐up. At 3 years, improvement in pain relief, physical functioning, emotional functioning and global improvement differed non‐significantly between local anaesthetics and anaesthetics and lavage. Compared with baseline, significant improvements (P < 0·05) in pain intensity, physical functioning, emotional functioning and global changes had occurred in both groups after 3 years. Because outcome measurements in the local anaesthetics and lavage and the local anaesthetics groups differed non‐significantly 3 years after treatment of painful TMJ disc displacement without reduction, use of lavage (50 mL saline) has an equivalent effect as local anaesthetics.     

Artificial Intelligence in Endodontics: Current Applications and Future Directions

IntroductionArtificial intelligence (AI) has the potential to replicate human intelligence to perform prediction and complex decision making in health care and has significantly increased its presence and relevance in various tasks and applications in dentistry, especially endodontics. The aim of this review was to discuss the current endodontic applications of AI and potential future directions.MethodsArticles that have addressed the applications of AI in endodontics were evaluated for information pertinent to include in this narrative review.ResultsAI models (eg, convolutional neural networks and/or artificial neural networks) have demonstrated various applications in endodontics such as studying root canal system anatomy, detecting periapical lesions and root fractures, determining working length measurements, predicting the viability of dental pulp stem cells, and predicting the success of retreatment procedures. The future of this technology was discussed in light of helping with scheduling, treating patients, drug-drug interactions, diagnosis with prognostic values, and robotic-assisted endodontic surgery.ConclusionsAI demonstrated accuracy and precision in terms of detection, determination, and disease prediction in endodontics. AI can contribute to the improvement of diagnosis and treatment that can lead to an increase in the success of endodontic treatment outcomes. However, it is still necessary to further verify the reliability, applicability, and cost-effectiveness of AI models before transferring these models into day-to-day clinical practice.     

Level of evidence in endodontics: what does it mean?

This review is a short summary of how the level of evidence in endodontics and endodontic research in particular is defined. The goal of this review is to help dentists and endodontists to become familiar with the evidence pyramid and thereby better evaluate the reliability of evidence on daily practices and choices in patient care. All medical treatment, including endodontic treatment, should be based on the best available evidence. In this review, the definition of evidence is presented and the different levels in the evidence pyramid are discussed with a special focus on endodontics. Much of the presently published endodontic research is done in vitro, which is regarded as the lowest level of evidence. However, it is important to understand that a low level of evidence does not mean that the research in itself is of poor quality or somehow unreliable. Instead, it means that one cannot draw conclusions from in vitro studies to clinical events with a high probability of accuracy. The in vitro results may be true, and often are, but more evidence from different types of studies such as case-control and cohort studies and even randomized controlled trials is needed to increase the probability that the results obtained in research do in fact correctly reflect the real events, e.g. level of probability of healing after a specific type of treatment for a specific disease. This review also discusses why the highest level of evidence may be difficult to obtain for a variety of practical and ethical reasons, and why not all endodontic treatment needs to be based on information from randomized controlled trials and systematic reviews.     

The Importance of Cone-beam Computed Tomography in the Management of Endodontic Problems: A Review of the Literature

Introduction

To obtain essential information in clinical endodontics, cone-beam computed tomographic (CBCT) imaging can be used in all phases of treatment including diagnosis, treatment planning, during the treatment phase, and through post-treatment assessment and follow-up. The purpose of this article was to review the use of CBCT imaging in the diagnosis, treatment planning, and assessing the outcome of endodontic complications.

Methods

Literature was selected through a search of PubMed electronic databases for the following keywords: tooth root injuries, tooth root radiography, tooth root perforation, tomography, cone-beam computed tomography, endodontic complications, tooth root internal/external resorption, root fractures, and broken instruments. The research was restricted to articles published in English. One hundred twelve articles met the inclusion criteria and were included in this review.

Results

Currently, intraoral radiography is the imaging technique of choice for the management of endodontic disease, but CBCT imaging appears to have a superior validity and reliability in the management of endodontic diagnosis and complications.

Conclusions

Endodontic cases should be judged individually, and CBCT imaging should be considered in situations in which information from conventional imaging systems may not yield an adequate amount of information to allow the appropriate management of endodontic problems. CBCT imaging has the potential to become the first choice for endodontic treatment planning and outcome assessment, especially when new scanners with lower radiation doses will be available.     

Endodontic follow-up practices,sources of knowledge,and self-assessed treatment outcome among general dental practitioners in Sweden and Norway

Abstract

Objective: To reduce the gap between what can be achieved in endodontic treatments and the observed treatment outcome among general dental practitioners, the present study set out to assess the status of the endodontic practices as regards to knowledge and self-assessed skills among general dental practitioners in Sweden and Norway.

Material and method: The questionnaire was sent to 1384 general dental practitioners. It contained questions regarding access to continuing education in endodontics, sources of knowledge for clinical management of patients, post-operative follow-ups, self-assessed success-rate, and the initial diagnosis impact on the outcome of endodontic treatments.

Results: The response rate was 61.4%. Almost half estimated their endodontic success-rate to be 90%. About two-thirds of the respondents did not know, or did not believe, that the initial diagnosis could affect the outcome of their endodontic treatments. Respondents who did not believe the diagnosis could impact the outcome were more likely to estimate their success rate as the highest (p<.001). Less than half performed post-operative follow-ups a year after treatment. A third of the respondents had not attended any continuing endodontic education.

Conclusion: Dentists who do not receive regular feedback on their treatments may lack insight into their own shortcomings. If this is combined with insufficient knowledge and understanding it may result in sub-par endodontic treatments being performed. It is important to have reliable ways to communicate current endodontic knowledge and to establish robust methods that may help dentists accurately assess their own performance in endodontics.     

Additional Treatment Indicative of an Unfavorable Endodontic Outcome in a Swedish County—A 10-year Observational Study

IntroductionThis study's aim was to calculate the incidence of first additional endodontic treatment or extraction as the result of an unfavorable endodontic outcome following orthograde root canal treatment (RCT) performed by general dental practitioners during a 10-year period and to identify possible predictors for outcomes.MethodsA randomized cohort of 280 individuals (and as many teeth) with an orthograde RCT was followed for over 10 years. Dental records were reviewed, and individuals were recalled when data were missing. The following terminal events indicative of unfavorable endodontic treatment outcome were orthograde retreatment, surgical endodontics, and tooth extractions exclusively due to endodontic reasons. Selected variables related to individuals and treatment (pre-, intra-, and postoperative) were harvested to analyze possible associations with the terminal events. Unadjusted survival analysis and Cox regression analysis were performed and P < .05 was considered statistically significant.ResultsTerminal events were registered for 22 teeth/individuals and 17 of these were orthograde retreatments. The cumulative 10-year survival of RCTs was 92.7% (standard error 1.7%), with a higher yearly incidence during the first 2 years. The univariate analysis identified 5 factors associated with the outcome. There were too few events to perform a multivariate analysis.ConclusionsThe mean incidence of additional treatment indicative of unfavorable endodontic outcome was 0.7% per year during the first 10 years, but the mean incidence was greater during the first 2 years. Five factors were associated with an unfavorable outcome; however, confounders cannot be excluded from the associations.     

The role of neural artificial intelligence for diagnosis and treatment planning in endodontics: A qualitative review

IntroductionThe role of artificial intelligence (AI) is currently increasing in terms of diagnosing diseases and planning treatment in endodontics. However, findings from individual research studies are not systematically reviewed and compiled together. Hence, this study aimed to systematically review, appraise, and evaluate neural AI algorithms employed and their comparative efficacy to conventional methods in endodontic diagnosis and treatment planning.MethodsThe present research question focused on the literature search about different AI algorithms and models of AI assisted endodontic diagnosis and treatment planning. The search engine included databases such as Google Scholar, PubMed, and Science Direct with search criteria of primary research paper, published in English, and analyzed data on AI and its role in the field of endodontics.ResultsThe initial search resulted in 785 articles, exclusion based on abstract relevance, animal studies, grey literature and letter to editors narrowed down the scope of selected articles to 11 accepted for review. The review data supported the findings that AI can play a crucial role in the area of endodontics, such as identification of apical lesions, classifying and numbering teeth, detecting dental caries, periodontitis and periapical disease, diagnosing different dental problems, helping dentists make referrals, and also helping them make plans for treatment of dental disorders in a timely and effective manner with greater accuracy.ConclusionAI with different models or frameworks and algorithms can help dentists to diagnose and manage endodontic problems with greater accuracy. However, endodontic fraternity needs to provide more emphasis on the utilization of AI, provision of evidence based guidelines and implementation of the AI models.     

Impact of Case Difficulty on Endodontic Mishaps in an Undergraduate Student Clinic

Introduction

The aim of this study was to identify the effect of case difficulty on the number of endodontic mishaps and the number of treatment visits using 2 different instrumentation methods, hand files, and reciprocating engine-driven WaveOne files (Dentsply Maillefer, Ballaigues, Switzerland) in an undergraduate student clinic.

Bioceramic materials in endodontics

During the past two decades, a number of major advances have been made in the field of bioactive ceramics used for endodontic treatment. This article reviews the physico-chemical and biological properties of bioceramic materials and the application of bioceramic technology to endodontics. Bioceramic materials, with their biocompatible nature and excellent physico-chemical properties, are widely used in endodontic applications. They can function as cements, root repair materials, root canal sealers and filling materials, which have the advantages of enhanced biocompatibility, potential increased root strength following obturation, antibacterial properties and sealing ability. New bioceramic materials have demonstrated the ability to overcome some of the significant limitations of earlier generations of endodontic materials. Most bioceramic materials have been shown to be biocompatible and have good physico-chemical characteristics, therefore having a potential use in clinical endodontics. Although in vitro studies on the use of bioceramic materials in endodontics have given encouraging results, randomized and double-blind clinical studies of sufficient length with these materials are needed to confirm long-term success following their use.     

Orascopy: a vision for the new millennium, Part 2

The advent of orascopy as a cutting edge technique has changed the way endodontists visualize as well as think about endodontics. As practitioners begin to see and understand endodontic etiology, it will enable oral physicians to provide treatment based on visual confirmation rather than radiographic estimates. In the future, conventional orascopic endodontics will be done very much like physicians provide treatment. It will be more qualitative rather than quantitative. Dentists will not need to make measurements of canals from radiographs; they will use orascopy to instrument, irrigate, and obturate while viewing the root canal system in real time. Surgical orascopic endodontics will continue to improve surgical treatment results because enhanced visualization has enabled endodontic surgeons to identify and treat endodontic etiology.     

Does the Etiology of Pulp Necrosis Affect Regenerative Endodontic Treatment Outcomes? A Systematic Review and Meta-analyses

ObjectiveTo evaluate if there is a connection between the causes of pulp necrosis (eg, caries, trauma, dental anomaly) and the success of regenerative endodontic treatment.MethodsElectronic databases (PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Embase) were searched for studies on regenerative endodontic treatment, which used both clinical and radiographic evaluation of root maturation after at least 6 months of follow-up. The search terms “necrotic pulp”, “regenerative endodontic treatment”, “revascularization”, and “revitalization” were combined using Boolean operators. The main journals on endodontics and dental traumatology were additionally hand-searched. Studies were included if they specified the causes of pulp necrosis. The primary question under review was, “Does the cause of pulp necrosis affect the outcome of regenerative endodontic treatment?” Other factors such as tooth type, intracanal medicament, irrigation protocol, use of a collagen matrix, and the type of scaffold were evaluated for possible relation with the outcome. The risk-of-bias assessment for randomized and nonrandomized studies was performed separately, using a modified Cochrane Collaboration's tool and risk of bias in non-randomized studies of interventions-I tool, respectively. Meta-analysis was performed, when possible, between studies comparing treatment outcomes of teeth whose pulp necrosis had different etiology. The search strategy yielded 1197 items. After screening, 18 studies reporting 445 regenerative endodontic treatment cases were included.ResultsThe overall success rate for 274 teeth with trauma etiology was 94.8%, for 95 teeth with dens evaginatus etiology was 93.1%, and for 24 teeth with caries etiology was 96%. No significant difference was found between the results of regenerative endodontic treatment among teeth with trauma, dens evaginatus, and caries etiology (P = .055). Meta-analysis of studies comparing teeth with caries vs dens evaginatus and those with trauma vs caries confirmed that there was no evidence for difference in outcomes.ConclusionFurther randomized studies specifically testing such hypothesis are needed to confirm the preliminary results of this review.