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Computed tomography in endodontic decision making
Malmö University, Faculty of Odontology (OD).
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Computed tomography has been used in dentistry as a complement to two-dimensional (2D) imaging since the 1980s. The advent of cone beam computed tomography (CBCT), a more modern computed tomog-raphy technique, meant a revolution in dento-maxillofacial imaging due to sharper images, with less radiation and at a lower cost than with mul-ti-slice computed tomography (MSCT), i.e., conventional medical com-puted tomography. However, CBCT still uses higher radiation doses and is more expensive for the patient than conventional 2D methods. CBCT is generally reported as more accurate than intra-oral radiographs to diagnose pathologies orconditions of interest in endodontics. The diagnostic process is, nevertheless, not only about radiographs and it is not certain that the use of CBCT will provide a different chain of actions, and ultimately result in a health benefit for the patient. There is thus a need to establish whether the added information of computed tomography has an impact on diagnosis and therapy choice in endodontics. Guidelines based on the best available evidence have been issued to as-sist clinicians in how to use CBCT. However, little is known about the decision process that drives dentists to request computed tomography and there is a need for more insight into this process. The aims of this thesis were to assess the influence of CBCT in diagno-ses and treatments choices and to gain insight into dentists’ decision process when requesting CBCT examinations. Study I Cases used were of a fictive standardised clinical history of asympto-matic root-filled maxillary molars from 34 consecutively included pa-tients in which MSCT and intra-oral radiographs taken simultaneously. All cases were analysed by five decision makers. Before and after MSCT assessments were 1-3 months apart. The results showed that MSCT does not improve therapy planning agreement among decision makers but it influences therapy changes within each decision maker, often to more aggressive therapies (e.g. more teeth extractions) Studies II and III The studies were prospective observational studies. The cases were au-thentic clinical scenarios presented to the decision makers who also were the actual caregivers. The same cases were used in both studies II and III involving 53 consecutive patients referred for CBCT using the the evidence based European Commission (EC) guidelines. Seven deci-sion makers in two different clinics participated and made before and after CBCT assessments during normal clinical praxis. The results showed that CBCT significantly influenced changes in diagnoses and therapy plans. The changes in therapies were often towards more ag-gressive therapies and are strongly correlated with changes in diagnoses. CBCT also improved statistically decision makers’ confidence in the assessments. The decision makers felt that CBCT had a positive impact on the patient’s health in a large number of patients, but this could not be controlled, and the assessment was not blinded. Study IV Fourteen strategically selected dentists (informants) that use CBCT for endodontic purposes were interviewed. The interviews were semi-structured. The informants narrated on their last three self-reported CBCT cases. The interviews’ transcripts were analysed by qualitative content analysis. The interpretation of the phenomenon of the decision of using CBCT examinations for endodontic purposes was made at two different levels: the explicit and the implicit content. The explicit con-tent revealed three categories as follows: “visualization as a desire”, “fa-cilitating tough decisions” and “allocation of responsibility”. The im-plict content was interpreted as: dentists working in Sweden seemed to have a clinical common sense that compensates for the unfamiliarity of the guidelines. On the other hand, a “safer than sorry” attitude counter-balanced (e.g when tackling difficult patients) the restriction induced by the common sense approach. There was a belief that the national regula-tory system worked as a gate-keeper for over usage.

Place, publisher, year, edition, pages
Malmö university , 2019. , p. 91
Series
Doctoral Dissertation in Odontology
Keywords [en]
endodontics, decision making, computed tomography, CBCT, cone beam, interviews, qualitative content analysis, diagnostic thinking efficacy, therapeutic efficacy
National Category
Dentistry
Identifiers
URN: urn:nbn:se:mau:diva-7716DOI: 10.24834/isbn.9789171049803Local ID: 28735ISBN: 9789171049803 (print)ISBN: 9789171049797 (print)OAI: oai:DiVA.org:mau-7716DiVA, id: diva2:1404656
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2022-06-27Bibliographically approved
List of papers
1. Computed tomography (CT) in the selection of treatment for root-filled maxillary molars with apical periodontitis
Open this publication in new window or tab >>Computed tomography (CT) in the selection of treatment for root-filled maxillary molars with apical periodontitis
Show others...
2016 (English)In: Dento-Maxillo-Facial Radiology, ISSN 0250-832X, E-ISSN 1476-542X, Vol. 45, no 5, p. 1-5, article id 20150391Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The aims of this study were to evaluate whether the use of CT facilitates agreement among endodontists in selecting treatments for root-filled maxillary molars with apical periodontitis and to assess the efficacy of CT in choosing a treatment for such teeth. METHODS: 39 root-filled maxillary molars from 34 patients with suspected apical periodontitis were independently evaluated by 4 endodontists and 1 postgraduate student (decision-makers). Treatment decisions were made based on intra-oral radiographs and a fictive clinical history. After 1-3 months, the same decision-makers repeated the examination of the same teeth but with additional information from a CT examination. Agreement between decision-makers with or without the availability of the CT results was measured with Cohen's kappa coefficient. Differences in selected treatments with or without accessibility to the CT results were plotted for the same endodontists using descriptive statistics. RESULTS: The agreement in assessments among endodontists was slight or fair before the CT results were available (range: 0.081-0.535). No increase was observed after reviewing the CT results (range: 0.116-0.379). After the use of CT, the treatment plan was changed 38-76% of the time by all decision-makers, and the changes affected 57.8% of the cases in the study. CONCLUSIONS: The endodontists in this study exhibited a low degree of agreement when choosing a treatment for root-filled maxillary molars with apical periodontitis. A CT examination of the investigated teeth did not result in a significantly higher degree of agreement, and CT frequently contributed to a shift in the selected therapy.

Place, publisher, year, edition, pages
British Institute of Radiology, 2016
Keywords
decision-making, endodontics, tomography
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-6320 (URN)10.1259/dmfr.20150391 (DOI)21688 (Local ID)21688 (Archive number)21688 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2020-07-01Bibliographically approved
2. The impact of cone beam computed tomography on the choice of endodontic diagnosis
Open this publication in new window or tab >>The impact of cone beam computed tomography on the choice of endodontic diagnosis
2015 (English)In: International Endodontic Journal, ISSN 0143-2885, E-ISSN 1365-2591, Vol. 48, no 6, p. 564-572Article in journal (Refereed) Published
Abstract [en]

AIM: To determine whether the outcome of cone beam computed tomography (CBCT) examinations performed in accordance with the European Commission guidelines in a clinical setting has an impact on choosing diagnoses in endodontics. METHODOLOGY: A prospective observational study was conducted. Fifty-three consecutive patients (81 teeth) from two different endodontic specialist clinics in Sweden were followed. After performing a thorough clinical examination (based on the history, clinical findings, and diagnostic tests such as intra-oral radiography), the examiner wrote down a preliminary diagnosis before CBCT examination. After the CBCT examination, a new diagnosis was made by the same examiner. Both the pre- and the post-CBCT examination diagnoses were plotted according to patients and teeth. The CBCT examinations were performed using similar equipment and protocols that were standardized amongst the clinics. RESULTS: The diagnoses were changed for at least one tooth in 22 patients (41%); overall, the diagnoses were changed for 28 teeth (35%). CONCLUSION: CBCT has a substantial impact on diagnostic thinking in endodontics when used in accordance with the European Commission guidelines.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keywords
cone beam computed tomography, decision-making, endodontics, diagnosis
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-5983 (URN)10.1111/iej.12350 (DOI)000354294300009 ()18907 (Local ID)18907 (Archive number)18907 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2022-06-27Bibliographically approved
3. The effect of cone beam CT (CBCT) on therapeutic decision-making in endodontics
Open this publication in new window or tab >>The effect of cone beam CT (CBCT) on therapeutic decision-making in endodontics
2014 (English)In: Dento-Maxillo-Facial Radiology, ISSN 0250-832X, E-ISSN 1476-542X, Vol. 43, no 4, article id 20130137Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The aim was to assess to what extent cone beam CT (CBCT) used in accordance with current European Commission guidelines in a normal clinical setting has an impact on therapeutic decisions in a population referred for endodontic problems. METHODS: The study includes data of consecutively examined patients collected from October 2011 to December 2012. From 2 different endodontic specialist clinics, 57 patients were referred for a CBCT examination using criteria in accordance with current European guidelines. The CBCT examinations were performed using similar equipment and standardized among clinics. After a thorough clinical examination, but before CBCT, the examiner made a preliminary therapy plan which was recorded. After the CBCT examination, the same examiner made a new therapy plan. Therapy plans both before and after the CBCT examination were plotted for 53 patients and 81 teeth. As four patients had incomplete protocols, they were not included in the final analysis. RESULTS: 4% of the patients referred to endodontic clinics during the study period were examined with CBCT. The most frequent reason for referral to CBCT examination was to differentiate pathology from normal anatomy, this was the case in 24 patients (45% of the cases). The primary outcome was therapy plan changes that could be attributed to CBCT examination. There were changes in 28 patients (53%). CONCLUSIONS: CBCT has a significant impact on therapeutic decision efficacy in endodontics when used in concordance with the current European Commission guidelines.

Place, publisher, year, edition, pages
British Institute of Radiology, 2014
Keywords
cone beam computed tomography, decision-making, endodontics, therapeutics
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-6513 (URN)10.1259/dmfr.20130137 (DOI)000335382800001 ()18868 (Local ID)18868 (Archive number)18868 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2022-06-27Bibliographically approved
4. 'Seeing is believing': a qualitative approach to studying the use of cone beam computed tomography in endodontics in Sweden.
Open this publication in new window or tab >>'Seeing is believing': a qualitative approach to studying the use of cone beam computed tomography in endodontics in Sweden.
2019 (English)In: International Endodontic Journal, ISSN 0143-2885, E-ISSN 1365-2591, Vol. 52, no 10, p. 1519-1528Article in journal (Refereed) Published
Abstract [en]

Aim: To gain insight into the decision processes of dentists when requesting a cone beam computed tomography (CBCT) examination in endodontic settings. Methodology: Fourteen dentists (eight female) 33–58 years of age (mean = 44) practising in Sweden were interviewed. Ten of the dentists were specialists in Endodontics. The absolute inclusion criterion was experience of referring patients for CBCT for endodontic reasons. The included dentists comprised a strategically selected diverse sample in terms of gender, age, work experience, educational background, location of practice, service affiliation and accessibility to CBCT. Data were obtained through semistructured interviews exposing the context of their last three self‐reported referrals. Dentists were encouraged to describe their experiences of the circumstances in their own words, aided by the interviewer's open‐ended questions. The interviews were audio‐recorded and transcribed verbatim. The text was analysed by qualitative content analysis. Results: The manifest content was organized into three categories that were defined as visualization as a desire, facilitating tough decisions and allocating responsibility. Conclusion: An overall theme (covering the latent content) was identified: A balance between clinical common sense and a ‘better safe than sorry’ attitude guides the use of CBCT in endodontic settings. Informants had high clinical standards, knowledge concerning radiation risks and good sense, which could compensate for their lack of knowledge of guidelines. The national radiation regulatory system was perceived to work as a slightly porous gatekeeper for over‐usage.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
cone beam computed tomography, decision-making, endodontics, interviews, qualitative content analysis, qualitative research
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-5710 (URN)10.1111/iej.13144 (DOI)000485318200013 ()31077614 (PubMedID)28912 (Local ID)28912 (Archive number)28912 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2022-06-27Bibliographically approved

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Mota de Almeida, Fernando José

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