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  • 1.
    Brodén, Joséphine
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Uncertainty in Endodontics: Strategies for Understanding and Management2022Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    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.

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  • 2.
    Brodén, Joséphine
    et al.
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Fransson, Helena
    Malmö University, Foresight.
    Vareman, Niklas
    Lunds universitet.
    Pigg, Maria
    Malmö University, Foresight.
    Reflection to enhance students' awareness of and comfort with uncertainty.Manuscript (preprint) (Other academic)
  • 3.
    Brodén, Joséphine
    et al.
    Department of Dental Medicine, Karolinska Institutet, Stockholm.
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Vareman, Niklas
    Department of Medical Ethics, Lund University.
    Fransson, Helena
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    “Experts already have the answers". A mixed methods study on dental students’ reflections on risk assessment of root filled teeth2023In: ESE Wladimir Adlivankine Research Prize, Education Prize and Original Research Abstracts, 2023, article id EP02Conference paper (Other academic)
    Abstract [en]

    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.

  • 4.
    Brodén, Joséphine
    et al.
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Vareman, Niklas
    Lunds universitet.
    Fransson, Helena
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    What is the relationship between certainty and experience?: A qualitative study on dental students’ reflections on risk assessment of root filled teeth.Manuscript (preprint) (Other academic)
  • 5.
    Havsed, Kristian
    et al.
    Malmö University, Faculty of Odontology (OD). Department of Pediatric Dentistry, Institute for Postgraduate Dental Education, Jönköping, Sweden; Centre for Oral Health, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
    Hänsel Petersson, Gunnel
    Malmö University, Faculty of Odontology (OD).
    Isberg, Per-Erik
    Department of Statistics, Lund University, Lund, Sweden.
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Svensäter, Gunnel
    Malmö University, Faculty of Odontology (OD).
    Rohlin, Madeleine
    Malmö University, Faculty of Odontology (OD).
    Multivariable prediction models of caries increment: a systematic review and critical appraisal.2023In: Systematic Reviews, E-ISSN 2046-4053, Vol. 12, no 1, article id 202Article in journal (Refereed)
    Abstract [en]

    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.

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  • 6.
    Jonsson Sjögren, Jakob
    et al.
    Malmö University, Faculty of Odontology (OD). Dental Research Department, Public Dental Health Service, 701 16 Örebro, Sweden.
    Kvist, Thomas
    Department of Endodontology, Institute of Odontology at the Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden.
    List, Thomas
    Malmö University, Faculty of Odontology (OD).
    Eliasson, Alf
    Dental Research Department, Public Dental Health Service, 701 16 Örebro, Sweden; School of Health and Medical Sciences, Örebro University, 701 82 Örebro, Sweden.
    EndoReCO,
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Characteristics and impact of pain from root-filled teeth: A practice-based cross-sectional study comparing painful teeth with and without signs of inflammatory dental disease2024In: The Journal of Oral & Facial Pain and Headache, ISSN 2333-0384 , E-ISSN 2333-0376 , Vol. 38, no 1, p. 64-76Article in journal (Refereed)
    Abstract [en]

    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

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  • 7.
    Lill, Linda
    Malmö University, Faculty of Health and Society (HS), Department of Social Work (SA). Malmö University, Foresight.
    Äldreomsorgsarbetet: om arbetsvillkor, kompetens, genusrelationer och professionalisering2018In: Äldreomsorg och åldrande: Från anhörigskap till krisberedskap / [ed] Finnur Magnússon, Studentlitteratur AB, 2018, p. 35-47Chapter in book (Other academic)
  • 8.
    Nagendrababu, Venkateshbabu
    et al.
    Department of Restorative Dentistry, College of Dental Medicine University of Sharjah Sharjah United Arab Emirates.
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Duncan, Henry F.
    Division of Restorative Dentistry, Dublin Dental University Hospital Trinity College Dublin Dublin Ireland.
    Abbott, Paul V.
    UWA Dental School The University of Western Australia Perth Western Australia Australia.
    Fouad, Ashraf F.
    University of Alabama at Birmingham Birmingham Alabama USA.
    Kruse, Casper
    Section of Oral Radiology and Endodontics, Department of Dentistry and Oral Health Aarhus University Aarhus Denmark;Center for Oral Health in Rare Diseases Aarhus University Hospital Aarhus Denmark.
    Patel, Shanon
    Department of Endodontics, Faculty of Dentistry Oral and Craniofacial Sciences at Kings' College London London UK.
    Rechenberg, Dan K.
    Department of Conservative and Preventive Dentistry University of Zürich Zürich Switzerland.
    Setzer, Frank C
    University of Pennsylvania School of Dental Medicine Philadelphia Pennsylvania USA.
    Rossi‐Fedele, Giampiero
    Adelaide Dental School The University of Adelaide Adelaide South Australia Australia.
    Dummer, Paul M. H.
    School of Dentistry, College of Biomedical and Life Sciences Cardiff University Cardiff UK.
    PRIDASE 2024 guidelines for reporting diagnostic accuracy studies in endodontics: A consensus‐based development2024In: International Endodontic Journal, ISSN 0143-2885, E-ISSN 1365-2591Article in journal (Refereed)
    Abstract [en]

    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.

  • 9.
    Olsson, Sara R
    et al.
    Malmö University, Faculty of Odontology (OD). Dental Research Department, Public Dental Health Service, Örebro, Sweden.
    Jonsson Sjögren, Jakob
    Malmö University, Faculty of Odontology (OD). Dental Research Department, Public Dental Health Service Örebro Sweden.
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Fransson, Helena
    Malmö University, Faculty of Odontology (OD).
    Eliasson, Alf
    Dental Research Department, Public Dental Health Service Örebro Sweden;Department of Dentistry, Faculty of Medicine and Health Örebro University Örebro Sweden.
    EndoReCo, .
    Endodontic Research Collaboration in Scandinavia .
    Kvist, Thomas
    Department of Endodontology, Institute of Odontology at the Sahlgrenska Academy University of Gothenburg Gothenburg Sweden.
    Interventions in root‐filled teeth identified in general dental practice: A 6‐year longitudinal observational study2024In: International Endodontic Journal, ISSN 0143-2885, E-ISSN 1365-2591Article in journal (Refereed)
    Abstract [en]

    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 at-tending the Public Dental Service in Örebro County were enrolled for study partici-pation 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  radio-lucency  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  re-ceived intervention during the six- year period.

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  • 10.
    Pigg, Maria
    et al.
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Fransson, Helena
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight.
    Klinisk riskbedömning av apikal parodontit vid rotfyllda tänder2019In: Vetenskap och beprövad erfarenhet Tandvård, VBE programmet och författarna , 2019, p. 57-70Chapter in book (Other academic)
  • 11.
    Senneby, Anna
    et al.
    Malmö University, Foresight. Malmö University, Faculty of Odontology (OD). Malmö University, Biofilms Research Center for Biointerfaces. Department of Oral Radiology, Skåne University Hospital, Malmö, Sweden.
    Fransson, Helena
    Malmö University, Foresight. Malmö University, Faculty of Odontology (OD). Department of Endodontics, Faculty of Odontology, Malmö University, Malmö, Sweden.
    Vareman, Niklas
    Department of Medical Ethics, Lund University, Lund, Sweden.
    What is risk? The challenge of defining ‘risk’ in caries risk assessment2024In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 83, p. 42-46Article in journal (Other academic)
  • 12.
    Watanabe, Takeshi
    et al.
    Aarhus Univ, Sch Business & Social Sci, Dept Psychol & Behav Sci, Aarhus, Denmark.;Tokushima Univ, Dept Prevent Med, Grad Sch Biomed Sci, Tokushima, Japan.;Tokushima Univ, Dept Prevent Med, Grad Sch Biomed Sci, 3-18-15 Kuramoto Cho, Tokushima 7708503, Japan..
    Sieg, Mette
    Aarhus Univ, Sch Business & Social Sci, Dept Psychol & Behav Sci, Aarhus, Denmark..
    Lunde, Sigrid Juhl
    Aarhus Univ, Sch Business & Social Sci, Dept Psychol & Behav Sci, Aarhus, Denmark..
    Persson, Mads
    Aarhus Univ, Sch Business & Social Sci, Dept Psychol & Behav Sci, Aarhus, Denmark..
    Taneja, Pankaj
    Aarhus Univ, Dept Dent & Oral Hlth, Sect Oral & Maxillofacial Surg & Oral Pathol, Aarhus, Denmark.;Scandinavian Ctr Orofacial Neurosci, Aarhus, Denmark.;Scandinavian Ctr Orofacial Neurosci, Malmö, Sweden..
    Baad-Hansen, Lene
    Scandinavian Ctr Orofacial Neurosci, Aarhus, Denmark.;Scandinavian Ctr Orofacial Neurosci, Malmö, Sweden.;Aarhus Univ, Dept Dent & Oral Hlth, Sect Orofacial Pain & Jaw Funct, Aarhus, Denmark..
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight. Scandinavian Ctr Orofacial Neurosci, Aarhus, Denmark.;Scandinavian Ctr Orofacial Neurosci, Malmö, Sweden..
    Vase, Lene
    Aarhus Univ, Sch Business & Social Sci, Dept Psychol & Behav Sci, Aarhus, Denmark..
    Nocebo response in dentistry: A systematic review and meta-analysis of adverse events in analgesic trials of third molar removal2023In: Journal of Oral Rehabilitation, E-ISSN 1365-2842, Vol. 50, no 4, p. 332-342Article, review/survey (Refereed)
    Abstract [en]

    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.

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  • 13.
    Watanabe, Takeshi
    et al.
    Aarhus University, Denmark ;Tokushima University Graduate School of Biomedical Sciences, Japan.
    Sieg, Mette
    Aarhus University, Denmark.
    Lunde, Sigrid Juhl
    Aarhus University, Denmark.
    Taneja, Pankaj
    Aarhus University, Denmark ; Scandinavian Center of Orofacial Neurosciences, Denmark, Sweden.
    Baad-Hansen, Lene
    Aarhus University, Denmark ; Scandinavian Center of Orofacial Neurosciences, Denmark, Sweden..
    Pigg, Maria
    Malmö University, Faculty of Odontology (OD). Malmö University, Foresight. Scandinavian Center of Orofacial Neurosciences, Denmark, Sweden.
    Vase, Lene
    Aarhus University, Denmark.
    What is the nocebo effect and does it apply to dentistry?: A narrative review2022In: Journal of Oral Rehabilitation, E-ISSN 1365-2842, Vol. 49, no 5, p. 586-591Article, review/survey (Refereed)
    Abstract [en]

    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.

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