BackgroundUncertainty is present in many situations in dental practice, but must not prevent wise clinical decision-making. Dental education should acknowledge uncertainty and teach useful management strategies. This study explored if dental students are aware of, and comfortable with uncertainty. The aims were to (i) measure students’ comfort or discomfort with and awareness of uncertainty while conducting risk assessment, and (ii) investigate whether a reflection exercise makes the students more aware of, and comfortable with, uncertainty.

MethodsIn January 2021, final-year students (n = 51) were randomized to either a structured written reflection exercise (intervention) or to a control exercise. Five months later, in June, each group was assigned the other exercise (cross-over design; ensuring a sufficient sample). Students’ statements of uncertainty and comfort were gathered using a developed questionnaire before and after the exercises. The students were blinded to which of the exercises was the intervention. The exercises and questionnaire were administered in mandatory sessions on an internet-based learning platform, ensuring anonymity and informed consent. Potential carryover effects were mitigated by analyzing intervention exercise data from both groups but control exercise data only from the first group.

ResultsAt baseline 80% (41/51) of the students stated feeling very uncertain, uncertain or neither certain nor uncertain about assessing the risk and 84% were comfortable or very comfortable with their ability to handle the situation, with no between-group differences. The majority, 57% (29/51) of the students stated that they thought an experienced colleague would feel certain or very certain. After the exercise in June, 36% (9/25) of the students exposed to the reflection exercise changed their statements on how certain they felt about their capacity to handle the case.

ConclusionsThe exercise did not affect the awareness of uncertainty and the students’ comfort with it, as the majority of students stated already feeling comfortable in their ability to handle the situation at baseline. However, the reflection exercise highlighted the students’ perception that experience is important in managing uncertainty. There is a need for further research to better understand students’ and teachers’ perception and attitudes to uncertainty and its effective management.

Clinical trial numberNot applicable.

Aim: To investigate what happens to cross-sectionally identified root-filled teeth over a 6-year period, regardless of the time that elapsed since primary root canal treatment, in a cohort of adult patients regularly attending a Public Dental Service. A secondary aim was to investigate how the cumulative events affecting root-filled teeth over the same time were associated with variables obtained from a baseline examination.

Methodology: Adult patients with ≥1 previously root-filled tooth and regularly attending the Public Dental Service in Örebro County were enrolled for study participation in 2015. General dental practitioners examined all identified root-filled teeth in this cohort at baseline using a standardized protocol and were also responsible for further decision-making and treatments. After six years, information on events of the root-filled teeth was collected from dental records. The highest rating (most invasive treatment) on a 5-point ordinal scale was used in the analyses. Regression analyses with stepwise selection were performed for associations between patient- and tooth-related factors and events.

Results: A total of 445 patients with 1007 root-filled teeth were followed the entire observation time. Twenty (2.0%) of the root-filled teeth had endodontic retreatment and 150 (14.9%) were extracted over six years. Among teeth with periapical radiolucency or pain, the majority did not undergo retreatment or extraction; however, the multivariate analysis demonstrated that retreatment or extraction was associated with baseline recordings of teeth with periapical radiolucency (p < .0001), tenderness to percussion (p < .0001), and poor coronal restoration (p < .0001).

Conclusions: This study corroborates the notion that in general dentistry, root-filled teeth with radiological signs of apical disease often remain untreated over time. Furthermore, it also reveals that root-filled teeth presenting with mild pain do not necessarily receive any intervention. However, teeth with baseline signs of apical periodontitis, pain, or inadequate coronal restoration were more likely to have received intervention during the six-year period.

Studies investigating the accuracy of diagnostic tests should provide data on how effectively they identify or exclude disease in order to inform clinicians responsible for managing patients. This consensus-based project was undertaken to develop reporting guidelines for authors submitting manuscripts, which describe studies that have evaluated the accuracy of diagnostic tests in endodontics. These guidelines are known as the Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) 2024 guidelines. A nine-member steering committee created an initial checklist by integrating and modifying items from the Standards for Reporting of Diagnostic Accuracy (STARD) 2015 checklist and the Clinical and Laboratory Images in Publications (CLIP) principles, as well as adding a number of new items specific to the specialty of endodontics. Thereafter, the steering committee formed the PRIDASE Delphi Group (PDG) and the PRIDASE Online Meeting Group (POMG) in order to collect expert feedback on the preliminary draft checklist. Members of the Delphi group engaged in an online Delphi process to reach consensus on the clarity and suitability of the items in the checklist. The online meeting group then held an in-depth discussion on the online Delphi-generated items via the Zoom platform on 20 October 2023. According to the feedback obtained, the steering committee revised the PRIDASE checklist, which was then piloted by several authors when preparing manuscripts describing diagnostic accuracy studies in endodontics. Feedback from this process resulted in the final version of the PRIDASE 2024 checklist, which has 11 sections and 66 items. Authors are encouraged to use the PRIDASE 2024 guidelines when developing manuscripts on diagnostic accuracy in endodontics in order to improve the quality of reporting in this area. Editors of relevant journals will be invited to include these guidelines in their instructions to authors.

To compare pain characteristics, impact of pain and characteristics of patients withpainful root-filled teeth with and without signs of inflammatory dental disease. Thiscross-sectional study was performed in the Public Dental Health services, RegionÖrebro County, Sweden. Adult patients with ≥1 root-filled tooth identified at theirregular check-up were included and assigned to one of two groups; those with ≥1sign of inflammatory dental disease (DD+) and those without any such sign (DD−).Patients/teeth were compared regarding pain characteristics (intensity, frequency,duration, quality and provoking factors), impact of pain (medication intake, impacton life) and patient characteristics as background factors (general health, other bodilyand orofacial pain). Statistics included descriptive data (frequency tables) and groupcomparisons (Chi-square, Fisher’s Exact and Mann-Whitney U-tests). The DD+ groupincluded 27 participants (30 teeth) and the DD− group 22 participants (23 teeth).On average, pain intensity was mild, the frequency most often recurrent, and theimpact was low. Average pain duration since onset exceeded 2 years in both groups.The only observed between-group differences were average pain intensity; 3.1 (0–10Numerical Rating Scale (NRS)) in DD− group compared to 1.6 for DD+ (p = 0.030),and tenderness to apical palpation; only reported in the DD+ group. The similaritiesin clinical presentation between the two groups underscore the difficulties in correctlydistinguishing between pain of odontogenic and non-odontogenic origin in root-filledteeth with a standard clinical investigation. Additional diagnostic methods need to beinvestigated for their ability to differentiate between tooth pain or discomfort of differentorigins

BACKGROUND: Multivariable prediction models are used in oral health care to identify individuals with an increased likelihood of caries increment. The outcomes of the models should help to manage individualized interventions and to determine the periodicity of service. The objective was to review and critically appraise studies of multivariable prediction models of caries increment.

METHODS: Longitudinal studies that developed or validated prediction models of caries and expressed caries increment as a function of at least three predictors were included. PubMed, Cochrane Library, and Web of Science supplemented with reference lists of included studies were searched. Two reviewers independently extracted data using CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) and assessed risk of bias and concern regarding applicability using PROBAST (Prediction model Risk Of Bias ASessment Tool). Predictors were analysed and model performance was recalculated as estimated positive (LR +) and negative likelihood ratios (LR -) based on sensitivity and specificity presented in the studies included.

RESULTS: Among the 765 reports identified, 21 studies providing 66 prediction models fulfilled the inclusion criteria. Over 150 candidate predictors were considered, and 31 predictors remained in studies of final developmental models: caries experience, mutans streptococci in saliva, fluoride supplements, and visible dental plaque being the most common predictors. Predictive performances varied, providing LR + and LR - ranges of 0.78-10.3 and 0.0-1.1, respectively. Only four models of coronal caries and one root caries model scored LR + values of at least 5. All studies were assessed as having high risk of bias, generally due to insufficient number of outcomes in relation to candidate predictors and considerable uncertainty regarding predictor thresholds and measurements. Concern regarding applicability was low overall.

CONCLUSIONS: The review calls attention to several methodological deficiencies and the significant heterogeneity observed across the studies ruled out meta-analyses. Flawed or distorted study estimates lead to uncertainty about the prediction, which limits the models' usefulness in clinical decision-making. The modest performance of most models implies that alternative predictors should be considered, such as bacteria with acid tolerant properties.

TRIAL REGISTRATION: PROSPERO CRD#152,467 April 28, 2020.

Aims: Reflection on a deeper level is recognized as an important skill to learn for undergraduate students since mastering reflection can be helpful throughout their future careers. The aim with this study was to (i) examine if short structured written reflections could stimulate deep reflection among a group of dental students and (ii) explore specifically how the students reflected on clinical experience in relation to uncertainty when assessing the risk for exacerbation of apical periodontitis in root filled teeth.Methods: Short reflections were written by 52 dental students at Malmö University in 2021. All students first answered some questions associated with the risk for exacerbation of apical periodontitis in a case with a root filled tooth with a diffuse widening of the periodontal ligament space. After this, they were asked to write short reflections following prompts developed specifically to stimulate reflection. For each student, the reflections were analyzed and the level of reflection according to the 4Rs framework (Reporting/responding, Relating, Reasoning, Reconstructing) was assessed. The written content in the reflections were analyzed by a qualitative method, Systematic Text Condensation (STC). Results: Thirteen of the students (25%) reached the deepest level of reflection, Reconstructing. Sixteen students (31%), reached only the most superficial level, Report/respond. Two themes about experience and lack of experience were identified in the reflections: Theme 1 “The meaning of clinical experience” and Theme 2 “Differences and similarities”. The themes were subdivided into nine subgroups and described in more detail the relationship between experience and certainty as perceived by the students.Conclusions: A short reflection exercise stimulated deep reflection in a proportion of, but not all, dental students. The students believed that certainty comes with experience even when there is a lack of scientific evidence.

BackgroundThe nocebo response refers to the phenomenon where non-specific factors, including negative verbal suggestion and treatment expectations, cause adverse events (AE) following a placebo treatment. Non-specific factors are also likely to influence AE occurrence following administration of active pharmacological treatments. ObjectiveThis meta-analysis aimed to estimate the nocebo response in dentistry by assessing the AEs prevalence in placebo- and active arms of randomised controlled trials (RCTs) assessing analgesic treatment following third molar (M3) surgery. MethodsA systematic search was performed in PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials. Eligible studies had to report the number of patients experiencing at least one drug-related AE (patients with AE >= 1) separately for the active and placebo arms. The proportion of patients with AE >= 1 and drug-related dropouts were pooled, and risk differences (RDs) between patients in the placebo- and active arm were calculated. ResultsIn 50 independent RCTs of 47 identified articles, the pooled rates of patients with AE >= 1 were 22.8% in the placebo arm and 20.6% in the active arm. The pooled rates of drug-related dropout were 0.24% in the placebo arm and 0.08% in the active arm. There were no significant RDs in patients with AE >= 1 and drug-related dropouts. ConclusionThese results show that patients in the placebo arm reported AEs to the same extent as patients receiving active treatment, suggesting that most AEs in analgesic medication following M3 surgery may be attributed to the nocebo phenomenon.

När en tandläkare ska besluta om vilken behandling som är lämpligast för en patient finns det många källor till osäkerhet. För att hantera denna osäkerhet finns det olika strategier. Några möjliga strategier är att försöka minska osäkerheten eller att acceptera den och lära sig att fatta beslut trots att man känner sig osäker. 

Det är osäkert vilken behandling som är mest effektiv för unga patienter där ett kariesangrepp har gjort att tandpulpan har blivit blottad. Antingen kan man göra en fyllning direkt på den blottade tandpulpan så att den ges möjlighet att läka, en så kallad pulpaöverkappning, eller så kan man avlägsna pulpan och rotfylla tanden. Det finns för- och nackdelar med båda behandlingarna. Studier har visat att nästan hälften av alla rotfyllningar på barn och ungdomar är av tekniskt dålig kvalitet och att många tänder uppvisar inflammation vid rotspetsen. För att minska osäkerheten och jämföra de båda behandlingarna studerades publicerad relevant litteratur om de båda behandlingarna i en systematisk litteraturöversikt. Resultaten från studierna användes sedan i en hälsoekonomisk modell som visade att det var kostnadseffektivt med pulpaöverkappning jämfört med att avlägsna pulpan och rotfylla tanden. 

Trots att vissa former av osäkerhet går att minska så kommer tandläkare alltid behöva ha förmågan att kunna fatta beslut trots att man inte är säker. För att hjälpa tandläkarstudenter att känna trygghet med att ta beslut trots osäkerhet utvecklades och testades en reflektionsövning på en grupp tandläkarstudenter som gick sitt sista år på tandläkarutbildningen. Övningen bestod av skriftliga reflektioner om ett fall med en rotfylld tand där studenterna skulle bedöma risken för framtida akutisering av en kvarstående infektion. Med en upprepad enkät undersöktes om reflektionsövningen kunde påverka hur osäkra och hur bekväma studenterna kände sig. Innehållet i de skriftliga reflektionerna analyserades sedan med kvalitativ metod.

Slutsatserna är att: 

Det saknas studier om rotfyllning efter att tandpulpan blivit blottad på grund av karies på barn och ungdomar. 

För unga patienter med en permanent tand med blottad tandpulpa på grund av karies är pulpaöverkappning kostnadseffektivt jämfört med avlägsnande av pulpan och efterföljande rotfyllning.

De flesta tandläkarstudenter som deltog i reflektionsövningen kände sig inte säkra på riskbedömningen av rotfyllda tänder men kände sig samtidigt säkra på sin förmåga att hantera patientfallet och bekväma med att de gjorde det bästa för patienten. Reflektionsövningen påverkade hur studenterna svarade på hur osäkra de trodde att en expert skulle vara och på hur säkra de var på sin egen förmåga. 

Studenterna trodde att klinisk erfarenhet leder till säkerhet även i fall där det saknas vetenskapliga bevis. Därför är det viktigt att de erfarna tandläkare som undervisar studenter visar att även en expert kan vara osäker.

Evidence for the nocebo effect, a phenomenon characterised by suboptimal treatment efficacy, worsening of symptoms, or the occurrence of adverse events caused by an individual's negative treatment expectations, is growing across a multitude of medical fields. Within dentistry, little attention has been paid to patients' negative expectations, despite a number of studies supporting the influence of related factors, such as dental fear and anxiety, on the severity of peri- and post-operative dental pain. Only recently, a small number of commentaries and letters have emerged, urging dentists to recognise the possible existence of nocebo effects in dentistry and its implications for patient care. The present review summarises essential evidence of the nocebo phenomenon especially in relation to pain and drug administration. Subsequently, an overview of the current evidence of the nocebo phenomenon in the dental field is presented. Finally, based on the general knowledge of the nocebo effect, the review indicates fruitful arrays of research into the nocebo effect in dentistry.