Background: Uncertainty 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.

Methods: In 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.

Results: At 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.

Conclusions: The 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.

Aim: In uncertain clinical situations, such as assessing the risk of exacerbation of apical periodontitis in root-filled teeth, un-dergraduate students can benefit from being trained to reflect. This study aimed to explore how students specifically reflectedon clinical experiences in relation to uncertainty when assessing a case involving a root-filled tooth with apical periodontitis.

Methodology: Short reflections were written by 52 dental students at Malmö University in 2021. All students were asked toreflect on the risk for exacerbation of apical periodontitis in a case with a root-filled tooth with a diffuse widening of the perio-dontal ligament space. The reflections were written according to prompts developed to stimulate reflection. For each student, thereflections were analysed by a qualitative method, Systematic Text Condensation (STC).

Results: The analysis of the qualitative data resulted in the formulation of two themes about experience and lack of experience:Theme 1 ‘The meaning of clinical experience’ and Theme 2 ‘Differences and similarities’. The themes were subdivided into ninesubgroups and described the relationship between experience and certainty.

Conclusions: The students believed that certainty comes with experience even when there is a lack of scientific evidence

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.

This paper is concerned with uncertainties and decision making in endodontics. Uncertainties are of different kinds; risk, fundamental uncertainty, ignorance and indeterminacy. The various types of uncertainties that are involved in the process of clinical making decisions are briefly reviewed in case of an injured vital pulp, a necrotic pulp with apical periodontitis and finally a root-filled tooth with a persistent apical lesion.

In many clinical cases a dentist may feel certain when for example diagnosing, deciding on treatment, or assessing the prognosis - in other cases many dentists may feel a degree of doubt or uncertainty. This paper aims to explore the philosophical concept of uncertainty and its different dimensions, using the condition "persistent apical periodontitis associated with a previously root filled tooth" as an example. Acknowledging that uncertainty exists in any clinical situation can be perceived as uncomfortable, as some might regard it as a weakness. While some types of uncertainty met in dental practice can be addressed and reduced, there are other types which are inevitable and must be accepted. To make sound decisions, it is pertinent that the dentist reflects on and values the consequences of uncertainty. In this paper, a conceptual model is presented by which the dentist can identify the type of uncertainty in a clinical case, making it possible to decide on a strategy on how to manage the uncertainty and its possible consequences, with the aim to support the dentist's care for their patients. The understanding that uncertainty exists and the ability to acknowledge and be comfortable with it when making decisions should be addressed throughout our professional career, and thus ought to be developed during undergraduate education. Some suggestions on how teachers could target this are given in the paper.

Dentists often experience uncertainty when deciding on the most effective treatment for a particular patient. There are various sources of uncertainty and different strategies for coping with it, such as reducing or accepting it and learning how to make decisions despite feeling uncertain.

The overall objectives of the thesis are to contribute with information that reduces uncertainty regarding the treatment of cariously exposed pulps in young permanent teeth and to improve dental education to ensure that future dental students manage well despite uncertainty.

By means of a systematic review and a model analysis, the thesis evaluates the available evidence and cost-effectiveness of a pulp capping procedure compared to a root canal treatment to reduce the uncertainty regarding the cost-effectiveness of treatments for young permanent teeth with vital pulps exposed by caries.

The thesis also addresses the acceptance of uncertainty. A reflection exercise was developed and tested in a group of dental students. Prompts from an established model were used to stimulate the students to write reflections during the risk assessment of a root-filled tooth. The effect of the reflections on the student’s awareness of and comfort with uncertainty was explored with a repeated questionnaire. The written reflections were analyzed with a qualitative method to explore how dental students reflected on clinical experience in relation to uncertainty.

In the systematic review, the success rate for pulp capping in children and adolescents varied between 64 and 100 percent in the included studies. The model indicated that pulp capping procedures are cost-effective compared to root canal treatment in teeth with pulp exposure due to caries. Fewer teeth were extracted after a pulp capping during the 9 years the patients were followed in the model and the cost for the initial treatment and follow-up treatments during this time period was lower compared to a root canal treatment.

The reflection exercise had an effect on the students’ responses to the questions regarding how certain they believed an experienced colleague would feel, and how certain they felt of their capacity to handle the case. Most students did not state that they felt certain about assessing the risk for exacerbation of apical periodontitis in root-filled teeth but felt certain of their own capacity to handle the case, as well as comfortable with their ability to handle the situation and do their best for the patient.

Three themes about experience and lack of experience were identified in the reflections: “the meaning of clinical experience”, “assumed differences regarding assessment” and “relating to the same risk factors”.

The following conclusions were drawn from the four studies:

For children and adolescents with pulp exposure due to caries, pulp capping procedures are cost-effective compared to root canal treatment, but there is a lack of prospective studies concerning root canal treatment. Moreover, the existing studies on pulp capping procedures are of low quality.

Most final-year dental students participating in a reflection exercise did not feel certain of their risk assessment of root-filled teeth but still felt certain of their capacity to handle the situation, as well as comfortable with their ability to do the best for the patient. The students believed that clinical experience leads to certainty even when the scientific evidence is lacking and experts who meet students have a great responsibility to be transparent with their own uncertainty.

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.

OBJECTIVE: To contribute with information on cost-effectiveness of pulp capping and root canal treatment of posterior permanent vital teeth in children and adolescents with pulp exposures due to caries. MATERIAL AND METHODS: Cost-effectiveness by means of a Markov simulation model was studied in a Scandinavian setting. In a simulated 12-year-old patient, treatment of pulpal exposure of a permanent tooth, either by the initial treatment pulp capping or root canal treatment, was followed for 9 years until the patient was 21. The model was based on outcome data obtained from published literature and cost data based on reference prices. RESULTS: In the simulated case, with the annual failure probalility (AFP) of 0.034 for pulp capping, the total cost for an initial treatment with pulp capping and any anticipated following treatments during the 9 years, was 367 EUR lower than for a root canal treatment as the initial treatment. After an initial treatment with pulp capping 10.4% fewer teeth, compared with initial root canal treatment, were anticipated to be extracted. Pulp capping was thus considered to be the cost-effective alternative. The sensitivity analyses showed that the AFP of a tooth requiring a root canal treatment after an initial pulp capping needed to be 0.2 before root canal treatment may be considered being the cost-effective treatment. CONCLUSIONS: This model analysis indicated initial treatment by pulp capping to be cost-effective compared to root canal treatment in children and adolescents with pulp exposures due to caries.

Objective. There is a lack of knowledge regarding the health economic consequences of pulp capping and root canal treatment in order to treat children’s and adolescents’ permanent teeth with pulp exposures due to caries. Therefore, the aim of this study was to study the cost effectiveness of performing a pulp capping compared to a root canal treatment in children and adolescents with pulp exposures due to caries. Methods. The cost effectiveness was studied by the use of a Markov simulation model where a simulated 12-year-old patient with a pulp exposure in a permanent tooth was followed for 9 years. The probability of making a transition from one health state to another was calculated from data retrieved after literature searches of published clinical studies. The outcome was measured as avoided extractions until the subject was 21 years old. The time spent on the two treatments was studied by sending a survey to general dentists. Costs were discounted with 3% annually. Results. Based on the answers from the general dentists, the cost for a pulp capping as the initial treatment was 138 EUR and the cost for a root canal treatment as the initial treatment was 608 EUR during the 9 years. We found that less teeth were extracted after a pulp capping than after a root canal treatment in this age group. Pulp capping was found to be cost effective (dominant) compared to root canal treatment as the initial treatment.

Purpose: To evaluate the available evidence on pulp capping procedures and root canal treatment in young permanent teeth with vital pulps exposed by caries. Methods: The study was conducted as a systematic review of the literature. Three databases, PubMed, Web of Knowledge, and The Cochrane Library were searched. Reference lists of relevant articles were hand searched. The quality of all relevant publications was rated. Results: Ten original scientific studies were included in the review. The quality was rated as low in all studies. The search failed to disclose any article directly comparing pulp capping and root canal treatment. The level of evidence was insufficient to draw any conclusions regarding the effectiveness of the two treatment concepts. High success rates are reported for pulp capping procedures in exposure due to caries, though it is not possible to compare them to success rates of root canal treatment. The review confirms the lack of high quality studies on the treatment of young permanent teeth with cariously exposed pulps.