Dental and endodontic-related stress amongst undergraduate students before and during the COVID-19 pandemic: A mixed-methods study

AIM

To determine and explain the principal sources of stress among preclinical and clinical dental undergraduate students with a particular focus on the stressors linked to endodontics.

METHODOLOGY

A mixed-methods study, with an explanatory sequential design, was employed. Volunteer students of second, third and fourth years were asked to complete both the Dental Environment Stress (DES) questionnaire and a bespoke questionnaire for endodontic-related stress assessment, which had 21 questions in common with the DES. The results were analysed by Kruskal-Wallis and Marginal Homogeneity tests. In the second part of the study, a qualitative phase was conducted through focus group interviews of students from each academic year included in the study. Interviews were analysed by inductive content analysis.

RESULTS

The DES questionnaire determined that for all years the most stressful domains were 'performance pressure', 'workload' and 'clinical training'. According to the endodontic stress questionnaire, the most stressful domains were 'self-efficacy beliefs', 'endodontic clinical training' and 'faculty and administration' in early years, while they were 'endodontic patient treatment', 'performance pressure in endodontics' and 'clinical training' in later years. Comparing questions common to both questionnaires revealed that the stress score was lower for the endodontic stress questionnaire than in the DES questionnaire for 17 questions, being significantly lower for 13 questions (p < 0.05) and significantly higher for no question. The qualitative study showed that students' dental and endodontic-related stress was linked to different domains: patient, clinical procedure, organization, staff, academic education, evaluation and COVID-19-related issues. Qualitative aspects highlighted the important role that patients and COVID-19 have played in student stress. However, they suggested a possible explanation for the lower endodontic stress observed in this dental university hospital, which was based on: the nature of the teaching in endodontics, the consensus between endodontic supervisors, the use of a logical, progressive procedure and the considerable experience that students gain over the years.

CONCLUSION

Students considered endodontics stressful; however, education can play a central role in reducing stress, particularly during the early parts of the undergraduate course.

Effectiveness of full Pulpotomy compared with Root canal treatment in managing teeth with signs and symptOms indicative of irreversible pulpitis: a protocol for prospectiVE meta-analysis of individual participant data of linked randomised clinical trials (PROVE)

BACKGROUND

Full pulpotomy has been proposed as an alternative to root canal treatment in teeth with signs and symptoms indicative of irreversible pulpitis (IRP), but the evidence is limited, relying on underpowered studies with a high risk of bias. The aim of this study is to conduct a prospective meta-analysis (PMA) of individual participant data of a series of individual randomised trials to provide robust evidence on the clinical and cost-effectiveness of pulpotomy compared with root canal treatment.

METHODS

Individual participant data will be obtained from a series of randomised trials designed and conducted by a consortium of multi-national investigators with an interest in vital pulp treatment. These individualised trials will be conducted using a specified protocol, defined outcomes, and outcome measures. Ten parallel-group randomised trials currently being conducted in 10 countries will provide data from more than 500 participants. The primary outcome is a composite measure defined as (1) the absence of pain indicative of IRP, (2) the absence of signs and symptoms indicative of acute or chronic apical periodontitis, and (3) the absence of radiographic evidence of failure including radiolucency or resorption. Individual participant data will be obtained, assessed, and checked for quality by two independent reviewers prior to the PMA. Pooled estimates on treatment effects will be generated using a 2-stage meta-analysis approach. The first stage involves a standard regression analysis in each trial to produce aggregate data on treatment effect estimates followed by an inverse variance weighted meta-analysis to combine these aggregate data and produce summary statistics and forest plots. Cost-effectiveness analysis based on the composite outcome will be undertaken as a process evaluation to evaluate treatment fidelity and acceptability by patients and dentists.

RESULTS

The research question and trial protocol were developed and approved by investigators in all 10 sites. All sites use shared resources including study protocols, data collection forms, participant information leaflets, and consent forms in order to improve flow, consistency, and reproducibility. Each site obtained its own Institutional Review Board approval, and trials were registered in appropriate open access platforms. Patient recruitment has started in most sites, as of July 2023.

DISCUSSION

PMA offers a rigorous, flexible, and efficient methodology to answer this important research question and provide results with improved generalisability and external validity compared with traditional trials and retrospective meta-analyses. The results of this study will have implications for both the delivery of clinical practice and structured clinical guidelines' development.

TRIAL REGISTRATION

PROSPERO CRD42023446809. Registered on 08 February 2023.

Development and preliminary validation of an Objective Structured Assessment of Technical Skills (OSATS) for a partial pulpotomy procedure

AIM

To develop an Objective Structured Assessment of Technical Skills (OSATS) tool for partial pulpotomy and to preliminary assess the validity of this tool. Secondary objectives were to check internal consistency as well as the interrater reliability of this specific checklist and to compare it with the previously validated global rating score (GRS).

METHODOLOGY

The study assessed three groups of dental participants (mix of practitioners or students) possessing differing levels of clinical experience (7 novices, 7 intermediates, 7 experts), during a partial pulpotomy procedure on a simulated tooth with deep caries, using a bespoke procedure-specific checklist (PSC) and the GRS. Two independent examiners received the study participants in groups of two, in order to be able to directly observe their actions and grade the different steps of the procedure from 1 to 5 on the PSC and GRS. The internal validity of the specific checklist was assessed using a Cronbach's alpha test. As the construct validity of such a tool can be determined when the tool differentiates performance based on the level of experience, the total score of the PSC of the three groups (e.g. novice group, intermediate group, experienced group) were compared using Kruskal-Wallis and post-hoc Mann-Whitney pairwise U test. The total scores of the GRS were also analysed in the same manner. A correlation test (Correlation Matrices Test) was carried out for the entire sample between the specific checklist and the GRS (on total score). The intraclass correlation coefficient was used to measure the degree of agreement between the two evaluators. The statistical analysis was performed with XLSTAT® and Statistica® (significance p = 0.05).

RESULTS

The partial pulpotomy specific checklist graded from 1 to five demonstrated good internal consistency (0.86) and a good interrater reliability (0.91), a correct construct validity (p generally <0.05) and a good positive correlation with the validated GRS (r=0.92).

CONCLUSIONS

To address the need to develop education in vital pulp treatment, and more specifically the technical skills assessment of partial pulpotomy, an OSATS specific checklist was developed and preliminary validated. The checklist will need to be validated in larger cohorts.

Preclinical 3D-printed laboratory simulation of deep caries and the exposed pulp reduced student anxiety and stress, while increasing confidence and knowledge in vital pulp treatment

Aim

To evaluate the impact of a preclinical laboratory session using 3D printed teeth on dental student stress, anxiety, confidence and knowledge when treating deep caries and pulp exposure.

Methodology

This was a two‐centre controlled study, with randomized distribution of students into two groups: a vital pulp treatment (VPT) lecture‐only (control) group and a VPT‐lecture combined with a VPT‐laboratory (experimental) group. In both universities, preclinical students with endodontic or operative dentistry laboratory sessions could participate. All students were invited to the lecture. Two weeks later (timepoint‐T1), both groups completed validated and bespoke questionnaires and scales to evaluate their stress (Stress‐VAS), anxiety (STAI Trait [T] and State [S]), self‐confidence and knowledge. Thereafter, only the experimental group attended the hands‐on laboratory session demonstrating the techniques of selective caries removal and partial pulpotomy on a commercial 3D‐printed tooth. Two weeks later (timepoint‐T2), the participants from both groups repopulated the same questionnaires and VAS. The control group had the laboratory session after the completion of the study. The statistical analysis was performed with Statistica® (significance p = .05). The homogeneity between the two samples was checked by Khi² and Student tests. Stress‐VAS, STAI‐S, confidence and knowledge scores were compared within each group, and between the two groups, at T1 and T2, with a repeated measures anova test (+/−Tukey post‐hoc test).

Results

The groups comprised 54 students each, with no statistical difference between the groups regarding demographic, academic data and STAI‐T score. The two groups had no significant difference of Stress‐VAS, STAI‐S, confidence and knowledge scores at T1 while they presented a significant difference in stress, anxiety and confidence scores at T2, but with no significant difference in knowledge score. However, knowledge score, as other parameters, improved significantly between T1 and T2 in the experimental group.

Conclusions

The addition of a laboratory session using 3D‐printed teeth that simulated deep caries and pulp exposure management, significantly reduced the stress and anxiety of students and increased their confidence. Within the limitations of this study, the benefit of introducing new technology in increasing student confidence and reducing stress offers opportunity for educational improvement in the VPT and cariology areas.

A protocol for the Development of Core Outcome Sets for Endodontic Treatment modalities (COSET): an international consensus process

Background

The outcome of endodontic treatment is generally assessed using a range of patient and clinician-centred, non-standardised clinical and radiographic outcome measures. This makes it difficult to synthesise evidence for systematic analysis of the literature and the development of clinical guidelines. Core outcome sets (COS) represent a standardised list of outcomes that should be measured and reported in all clinical studies in a particular field. Recently, clinical researchers and guideline developers have focussed on the need for the integration of a patient-reported COS with clinician-centred measures. This study aims to develop a COS that includes both patient-reported outcomes and clinician-centred measures for various endodontic treatment modalities to be used in clinical research and practice.

Methods

To identify reported outcomes (including when and how they are measured), systematic reviews and their included clinical studies, which focus on the outcome of endodontic treatment and were published between 1990 and 2020 will be screened. The COSs will be defined by a consensus process involving key stakeholders using semi-structured interviews and an online Delphi methodology followed by an interactive virtual consensus meeting. A heterogeneous group of key ‘stakeholders’ including patients, general dental practitioners, endodontists, endodontic teachers, clinical researchers, students and policy-makers will be invited to participate. Patients will establish, via interactive interviews, which outcomes they value and feel should be included in a COS. In the Delphi process, other stakeholders will be asked to prioritise outcomes identified from the literature and patient interviews and will have the opportunity at the end of the first round to add outcomes that are not included, but which they consider relevant. Feedback will be provided in the second round, when participants will be asked to prioritise the list again. If consensus is reached, the remaining outcomes will be discussed at an online meeting and agreement established via defined consensus rules of outcome inclusion. If consensus is not reached after the second round, a third round will be conducted with feedback, followed by the online meeting. Following the identification of a COS, we will proceed to identify how and when these outcomes are measured.

Discussion

Using a rigorous methodology, the proposed consensus process aims to develop a COS for endodontic treatment that will be relevant to stakeholders. The results of the study will be shared with participants and COS users. To increase COS uptake, it will also be actively shared with clinical guideline developers, research funders and the editors of general dental and endodontology journals.

Trial registration

COMET 1879. 21 May 2021.

MMP-9 Levels and NaOCl Lavage in Randomized Trial on Direct Pulp Capping

Outcome expectations of direct pulp capping in carious teeth are obscured by a clinically unknown infiltration and breakdown of the dental pulp tissue. Histologic studies showed that this soft tissue breakdown is related to the innate immune system. We hypothesized 1) that a neutrophil biomarker could predict the outcome of direct pulp capping and 2) that using sodium hypochlorite (NaOCl) as a lavage solution to remove necrotized infected pulp tissue could improve it. In this randomized trial in mature posterior teeth causing no or mild discomfort with carious pulpal exposures, pulpal fluid was collected to assess neutrophil gelatinase (matrix metalloproteinase 9 [MMP-9]) per total protein (TP) levels as a predictive local biomarker. Subsequently, the dentin-pulp wound was randomly washed with a 2.5% NaOCl or a physiologic saline solution (1:1 allocation), capped with mineral trioxide aggregate, and the tooth was immediately restored with a resin-based composite restoration. Ninety-six patients were included, and 84 individuals could be followed up to treatment failure or clinically confirmed pulp survival after a minimum of 1 y. The entire data were fitted to a Cox proportional hazards model to assess the influence of the observational variables MMP-9/TP and discomfort with the randomized lavage treatment on pulp survival. The Kaplan-Meier pulp survival rates after 1 y were 55% for saline and 89% for NaOCl lavage. The inflammatory state of the pulp tissue as reflected by MMP-9/TP levels and NaOCl lavage had a highly significant (P < 0.001 and P = 0.004, respectively) impact on pulp survival, while mild preoperative discomfort did not. In conclusion, MMP-9/TP showed great promise as a predictive local biomarker, and NaOCl lavage considerably improved the survival time of cariously exposed and directly capped pulps.

The association between apical periodontitis and adverse pregnancy outcomes: a systematic review

BACKGROUND

The association between adverse pregnancy outcomes (APOs) and maternal apical periodontitis remains unclear as it has not been examined rigorously or reviewed systematically.

OBJECTIVE

To systematically review and critically evaluate the available evidence on the association of maternal apical periodontitis with several APOs.

METHODS

A literature search was conducted using the following electronic databases: Clarivate Analytics' Web of Science, Scopus, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL), from inception to 25 February 2021, with no language restrictions. Observational studies including longitudinal clinical trials, cohort, case-control and cross-sectional studies of prospective and retrospective design were included. Articles with duplicate or overlapping results, abstract-only papers, case reports, case series, animal studies and reviews were excluded. Two independent reviewers were involved in study selection, data extraction and appraising the included studies; disagreements were resolved by a third reviewer. The Newcastle-Ottawa Scale (NOS) and the adapted form of the NOS were used to assess the quality for case-control and cross-sectional studies, respectively.

RESULTS

Two case-control and one cross-sectional study were included in the current review. The included studies were published between 2015 and 2017, with a total of 1187 participating individuals with an approximate age range of 15 to 40 years. As the included studies reported different outcomes, the heterogeneity of data prevented a meta-analysis being undertaken. The overall quality of the evidence was 'Fair' for two out of three included studies, while one study was categorized as 'Good'.

DISCUSSION

Two out of three included primary studies had a substantial number of methodological inconsistencies and flaws, and therefore caution should be exercised in interpreting the results of this systematic review because several important covariates were not considered in the original investigations.

CONCLUSION

Based on a limited volume and 'Fair' and 'Good' quality of evidence, a positive association between maternal apical periodontitis and APOs was observed. However, more 'Good' quality clinical studies are needed to confirm the results of the current review.

FUNDING

None REGISTRATION: PROSPERO database (CRD42-2191987).

Outcome measures to assess the effectiveness of endodontic treatment for pulpitis and apical periodontitis for use in the development of European Society of Endodontology (ESE) S3 level clinical practice guidelines: a protocol

The European Society of Endodontology (ESE) is in the process of developing S3Level Clinical Practice Guidelines for the treatment of pulpal and apical disease for the benefit of clinicians and patients. In order to ensure a homogenous review process in the development of the clinical practice guidelines, it is essential that the core outcomes for all endodontic treatments are standardized and recommendations are made regarding minimum follow-up time specific to each outcome measure. In the absence of a recognized core outcome set in Endodontics, the current project aimed to follow an established consensus process to define the most appropriate clinician and patient-reported outcomes. As part of the project, recommendations will also be agreed regarding an acceptable minimum follow-up period for studies by literature review and group discussion. The selected outcome measures and follow-up periods will be used in subsequent systematic analyses of the literature to investigate the effectiveness of endodontic treatment to alleviate pulpitis and apical periodontitis. In this paper, previous reviews, ESE Guidelines and Position Statements were searched in order to compile a list of potentially important outcome measures for the treatment of pulpitis (working group 1), the nonsurgical treatment of apical periodontitis (working group 2), the surgical treatment of apical periodontitis (working group 3) and the regenerative treatment of apical periodontitis (working group 4). Initially, the two S3 guideline leads selected two independent senior clinical academics with experience of evidence-based dentistry to lead each of the four working groups forming a 10-member steering group. The working group leads in turn selected 32 academics with experience of evidence-based dentistry to lead the individual systematic reviews contained within the respective working groups. These 42 individuals make up the Guideline Development Group (GDG). Prior to the selected systematic reviewers commencing writing and submitting the review protocol, the complete list of outcome variables identified in this document will be ranked by the 42 members of the GDG in their importance to the individual patient using a 9-point Likert scale. A summary of the survey scores will thereafter be shared with the members of the group and the final list of clinician and patient-reported outcome measures rated as critical for decision making (7-9 on Likert scale by majority of survey participants) to guide systematic reviews will be consented and confirmed during an online meeting of the steering group. In this online meeting, another aspect with regard to meaningfulness of clinical trial results to be addressed in systematic reviews will be consented: length of follow-up. In order to develop high quality guidelines, it is suggested that the follow-up period after treatment should be related to the specific outcome measure being addressed; however, a minimum of one year for assessing the effectiveness of treatments for pulpitis and apical periodontitis should be considered. It is accepted, that selected research questions that focus on pain, swelling, medication taken or investigating diagnostic accuracy are likely to have shorter follow-up periods. As a result of the GDG consensus process, the outcome measures and length of follow-up will, alongside the use of standard instruments to assess the methodological quality of clinical trials and other comparative studies, be applied to all the commissioned systematic reviews that will inform the subsequent process when developing the ESE S3 Level Clinical Practice Guidelines.

Critical analysis of the reporting quality of randomized trials within Endodontics using the Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 quality standard checklist

AIM

To critically evaluate the reporting quality of a random sample of clinical trials published in Endodontics against the PRIRATE 2020 checklist and to analyse the association between the quality of reported trials and a variety of parameters.

METHODOLOGY

Fifty randomized clinical trials relating to Endodontics were randomly selected from the PubMed database from 2015 to 2019 and evaluated by two independent reviewers. For each trial, a score of '1' was awarded when it fully reported each item in the PRIRATE guidelines whereas a score of '0' was awarded when an item was not reported; when the item was reported inadequately a score of '0.5' was awarded. For the items that were not relevant to the trial, 'Not Applicable (NA)' was given. Based on the interquartile range of the overall scores received, trials were categorized into 'Low' (0-58.4%), 'Moderate' (58.5-72.8%) and 'High' (72.9-100%) quality. The associations between characteristics and quality of clinical trials were investigated. Descriptive statistics, frequency analysis and percentage analyses were used to describe the data. To determine the significance of categorical data, the chi-square test was used. The probability value 0.05 was considered as the level of significance.

RESULTS

Based on the overall scores, 13 (26%), 25(50%) and 12 (24%) of the reports of clinical trials were categorized as 'High', 'Moderate' and 'Low' quality, respectively. Three items (1b, 6d, 11e) were adequately reported in all manuscripts whilst two items (5k, 5m) were scored 'NA' in all the reports. The reports published from Europe had a significantly greater percentage of 'High'-quality scores, compared to Asia, Middle East, North America and South America (P = 0.0002). The 'High'-quality reports were published significantly more often in impact factor journals (P = 0.045). Reports of clinical trials published in journals that adhered to the CONSORT guidelines had significantly more 'High' scores compared to those that did not (P = 0.008). Clinical trials with protocols registered a priori had a significantly greater percentage of 'High' scores compared to the trials that were not registered in advance (P = 0.003). No significant difference occurred between the quality of clinical trials and the number of authors, journal (Endodontic specialty vs. Non-Endodontic specialty) or year of publication.

CONCLUSIONS

Reports of randomized clinical trials published in the speciality of Endodontics had a substantial number of deficiencies. To create high-quality reports of clinical trials, authors should comply with the PRIRATE 2020 guidelines.

Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) guidelines: a development protocol

Diagnostic accuracy studies play an important role in informing clinical practice and patient management, by evaluating the ability of diagnostic testing and imaging to identify the presence or absence of a disease or condition. These studies compare the relative diagnostic strength of the test or device with a reference standard, therefore, guiding clinical decisions on the reliability of the test, the need for further tests, and whether to monitor or treat a particular condition. Inadequate and incomplete reporting of diagnostic accuracy studies can disguise methodological deficiencies and ultimately result in study bias and the inability to translate research findings into daily clinical practice. The Preferred Reporting Items for Diagnostic Accuracy Studies in Endodontics (PRIDASE) guidelines are being developed in order to improve the accuracy, transparency, completeness and reproducibility of diagnostic accuracy studies in the speciality of Endodontology. The aim of this paper is to report the process used to develop the PRIDASE guidelines based on a well-established consensus process. The project leaders (PD, VN) formed a steering committee of nine members (PD, VN, PA, AF, DR, SP, CK, MP, HD) to oversee and manage the project. The PRIDASE steering committee will develop the initial draft of the PRIDASE guidelines by adapting and modifying the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 guidelines, adding new items related specifically to the nature of Endodontics and incorporate the Clinical and Laboratory Images in Publication (CLIP) principles. The initial guidelines will consist of a series of domains and individual items and will be validated by the members of a PRIDASE Delphi Group (PDG) consisting of a minimum of 30 individuals who will evaluate independently the individual items based on two parameters: 'clarity' using a dichotomous scoring (yes/no) and 'suitability' for inclusion using a 9-point Likert Scale. The scores awarded by each member and any suggestions for improvement will be shared with the PDG to inform an iterative process that will result in a series of items that are clear and suitable for inclusion in the new PRIDASE guidelines. Once the PDG has completed its work, the steering committee will create a PRIDASE Meeting Group (PMG) of 20 individuals from around the world. Members of the PDG will be eligible to be the part of PMG. The draft guidelines and flowchart approved by the PDG will then be presented for further validation and agreement by the PMG. As a result of these discussions, the PRIDASE guidelines will be finalized and then disseminated to relevant stakeholders through publications and via the Preferred Reporting Items for study Designs in Endodontology (PRIDE) website (http://pride-endodonticguidelines.org). Periodic updates to the PRIDASE guidelines will be made based on feedback from stakeholders and end-users.

Efficacy of direct pulp capping for management of cariously exposed pulps in permanent teeth: a systematic review and meta-analysis

BACKGROUND

The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis.

OBJECTIVES

To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome.

METHODS

Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality.

RESULTS

Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine.

DISCUSSION

These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI.

CONCLUSIONS

Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.

Glossary for randomized clinical trials

Randomized clinical trials are positioned at the highest level of primary clinical evidence, as they are designed to be unbiased with a reduced risk of systematic error. The Consolidated Standards of Reporting Trials (CONSORT) statement was first developed in 1996 to improve the reporting quality of randomized clinical trials with updates being published subsequently. Recently, the Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 guidelines were developed exclusively for the field of Endodontics to address the suboptimal quality of randomized clinical trials submitted to Endodontic journals, which result in many being rejected. A principal flaw in submissions is the fact that many authors are unclear on the keys terms that should be used when developing manuscripts for publication. Clearly, authors should be aware of the most common terms used when conducting and reporting randomized clinical trials. Hence, the aim of the current paper is to present a comprehensive glossary of the terminology used in randomized clinical trials in order to assist authors when designing, executing and writing-up randomized clinical trials.

The management of deep carious lesions and the exposed pulp amongst members of two European endodontic societies: a questionnaire-based study

AIMS

To investigate and compare views on management of deep caries and the exposed pulp by Endodontic Society members in Ireland (Irish Endodontic Society [IES]) and Italy (Accademia Italiana di Endodonzia [AIE]). Further aims were to investigate the influence of patient-related factors (age, symptoms) and operator-related factors (material choice, antibiotics) on management.

METHODOLOGY

A structured online questionnaire containing two cases (an 18- and 45-year-old) and two scenarios (± mild symptoms), including history and radiograph, was sent to IES and AIE members. The answers were analysed using chi-square and Fisher's exact test (P < 0.05).

RESULTS

In total, 120 dentists participated, representing 49% of the AIE and 48% of the IES membership. Age distribution was similar between the societies; however, most AIE members had no further qualifications (63%), while IES respondents generally had a postgraduate endodontic qualification (71%). AIE respondents carried out a larger volume of vital pulp treatment (VPT) per month, with 69% carrying out over five cases, compared with 22% of IES respondents. The presence of patient symptoms significantly altered treatment planning decisions (P < 0.001) with root canal treatment (RCT) more frequently selected in both societies. Patient age significantly influenced treatment choice in the absence (P = 0.043) or presence (P = 0.012) of symptoms with less VPT advocated in older patients. There were no significant differences in the treatment of a young patient in the presence (P = 0.302) or absence of symptoms (P = 0.297); however, older patient management differed between the societies for symptomatic (P = 0.041) and asymptomatic scenarios (P = 0.044) with significantly more RCTs carried out in the AIE than the IES. Hydraulic calcium silicate materials were commonly selected, accounting for 81% of IES and 69% of AIE VPT materials, although younger members of the AIE preferred calcium hydroxide materials. Younger dentists in both societies prescribed less RCT than older age groups.

CONCLUSIONS

Although VPT is carried out by members of both societies there was no consistency regarding the most appropriate management for the exposed pulp or the VPT material of choice. Patient symptoms and age significantly influence the decision-making process and invasiveness of treatment. Hydraulic calcium silicate materials were the most commonly advocated material in all groups except young AIE members who preferred calcium hydroxide.

Frightened of the pulp? A qualitative analysis of undergraduate student confidence and stress during the management of deep caries and the exposed pulp

AIM

To evaluate sources of student confidence and stress during the management of deep carious lesions and the exposed pulp during undergraduate clinics. Further aims were to identify barriers and facilitators, which could result in educational or practical improvements in the delivery of teaching and provision of treatment in this area.

METHODOLOGY

A exploratory qualitative study design was used, based on recorded focus group interviews, guided by 12 predetermined questions. The discussions were transcribed verbatim and analysed by inductive qualitative content analysis. Common categories were identified to aid understanding. Forty undergraduate dental students from 4th and 5th years in Dublin Dental University Hospital participated in the study.

RESULTS

Student stress and confidence were multifactorial and broadly linked to specific domains: clinical procedure, academic education, clinical training, evaluation/grading, organization and equipment, vital pulp biomaterial and the patient. Most students expressed a preference for one-stage selective carious removal to soft dentine rather than potential pulp exposure in deep carious lesions, noting that although it helped to decrease their immediate stress, it also caused longer-term concern by leaving caries close to the pulp. Nevertheless, their confidence was affected by limited clinical experience of carrying out selective removal procedures in deep caries. A recurrent finding was students citing high levels of stress after pulp exposure. Feelings including anger, fear, embarrassment and denial were associated with pulp exposure during deep caries management. Generally, the students felt able to manage pulp capping procedures, but were less certain about partial pulpotomy, suggesting that although they are aware of its advantages, they were unsure about the appropriate volume of pulp tissue to remove. To reduce stress, students suggested that laboratory teaching should employ new 3-D printed solutions and clinics should establish clear consensus amongst supervising teachers about the best way to manage the exposed pulp.

CONCLUSIONS

Students lacked confidence as they neared the pulp and prefer selective caries removal techniques, which reduce the likelihood of pulp exposure. Students identified stressors and suggested improvements in several domains that would improve confidence. These ameliorations could lead to enhancements in student ability to perform these conservative techniques, and improve the provision of treatment in this area.

Dissecting dentine-pulp injury and wound healing responses: consequences for regenerative endodontics

A thorough understanding of the biology of the dentine-pulp complex is essential to underpin new treatment approaches and maximize clinical impact for regenerative endodontics and minimally invasive vital pulp treatment (VPT) strategies. Following traumatic and carious injury to dentine-pulp, a complex interplay between infection, inflammation and the host defence responses will occur, which is critical to tissue outcomes. Diagnostic procedures aim to inform treatment planning; however, these remain clinically subjective and have considerable limitations. As a consequence, significant effort has focussed on identification of diagnostic biomarkers, although these are also problematic due to difficulties in identifying appropriate diagnostic fluid sources and selecting reproducible biomarkers. This is further compounded by the link between inflammation and repair as many of the molecules involved exhibit significant multifunctionality. The tertiary dentine formed in response to dental injury has been purposefully termed reactionary and reparative dentine to enable focus on associated biological processes. Whilst reactionary dentine produced in response to milder injury is generated from surviving primary odontoblasts, reparative dentine, in response to more intense injury, requires the differentiation of new odontoblast-like cells derived from progenitor/stem cells recruited to the injury site. These two diverse processes result in very different outcomes in terms of the tertiary dentine produced and reflect the intensity rather than specific nature (nonexposure versus exposure) of the injury. The subsequent identification of the odontoblast-like cell phenotype remains challenging due to lack of unique molecular or morphological markers. Furthermore, the cells ultimately lining the newly deposited dentine provide only a snapshot of events. The specific source and plasticity of the progenitor cells giving rise to the odontoblast-like cell phenotype are also of significant debate. It is likely that improved characterization of tertiary dentine may better clarify the influence of cell derivation for odontoblast-like cells and their diversity. The field of regenerative endodontics offers exciting new treatment opportunities, and to maximize outcomes, we propose that the term regenerative endodontics should embrace the repair, replacement and regeneration of dentine-pulp.

Management of deep caries and the exposed pulp

Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one-visit as indirect pulp treatment or two-visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re-emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp-dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence-based management strategies and education in management of the exposed pulp are critical in the future.

PRISMA for abstracts: best practice for reporting abstracts of systematic reviews in Endodontology

An abstract is a brief overview of a scientific, clinical or review manuscript as well as a stand-alone summary of a conference abstract. Scientists, clinician-scientists and clinicians rely on the summary information provided in the abstracts of systematic reviews to assist in subsequent clinical decision-making. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Abstracts checklist was developed to improve the quality, accuracy and completeness of abstracts associated with systematic reviews and meta-analyses. The PRISMA for Abstracts checklist provides a framework for authors to follow, which helps them provide in the abstract the key information from the systematic review that is required by stakeholders. The PRISMA for Abstracts checklist contains 12 items (title, objectives, eligibility criteria, information sources, risk of bias, included studies, synthesis of results, description of the effect, strength and limitations, interpretation, funding and systematic review registration) under six sections (title, background, methods, results, discussion, other). The current article highlights the relevance and importance of the items in the PRISMA for Abstracts checklist to the specialty of Endodontology, while offering explanations and specific examples to assist authors when writing abstracts for systematic reviews when reported in manuscripts or submitted to conferences. Strict adherence to the PRISMA for Abstracts checklist by authors, reviewers, and journal editors will result in the consistent publication of high-quality abstracts within Endodontology. This article is protected by copyright. All rights reserved.

A re-audit of the technical quality of undergraduate root canal treatment after the introduction of new technology and teaching practices

AIM

To revaluate through re-audit the technical quality of undergraduate nonsurgical root canal treatment (RCTx) in a dental teaching hospital as a result of recommended changes to teaching practices.

METHODOLOGY

The technical quality of undergraduate RCTx was evaluated radiographically after educational changes and the mandatory introduction of new technologies (nickel-titanium files, apex locators, greater taper gutta-percha points) in 182 root canals. Evaluation was based on four criteria: presence of voids, root canal filling termination (0-2 mm of radiographic apex), all roots filled and the prepared canal contained the original anatomy. Chi-squared analysis was used to determine statistically significant improvements in quality between the respective audits (P < 0.05).

RESULTS

Twenty-three of the 40 canals in single-rooted teeth (57.5%) and 68 of the 129 (52.7%) canals in multirooted teeth analysed had an acceptable root filling. This compared with 48% of canals in single-rooted teeth and 38% of canals in multirooted teeth in the original audit. Specifically, the frequency of root canal voids and unsatisfactory apical root filling termination were reduced in multirooted teeth by 23% and 14% and in single-rooted teeth by 11% and 12%, respectively, compared with the original audit. When multirooted teeth were taken as one unit, 45.2% were considered to be acceptable, significantly better than the 18.8% multirooted teeth in the original audit (P = 0.042). Deviations from the canal anatomy on radiographic examination were rare findings in both audits.

CONCLUSIONS

Changes to endodontic teaching practices significantly improved the technical standards of undergraduate root filling in multirooted teeth. The regular auditing of undergraduate teaching practice is necessary to inform current teaching, instigate change and improve standards.

Prospective audit of postoperative instructions to patients undergoing root canal treatment in the DDUH and re-audit following introduction of a written patient information sheet

STATEMENT OF THE PROBLEM

Concerns were expressed that postoperative written instructions following endodontic treatment are not available in the Dublin Dental University Hospital.

MATERIALS AND METHODS

Data was collected in three phases: retrospective analysis of clinical notes for evidence of the delivery of postoperative instructions; a randomly distributed questionnaire to patients undergoing root canal treatment prior to the introduction of a written postoperative advice sheet; and, another survey following introduction of the advice sheet.

RESULTS

Some 56% of patients' charts documented that postoperative advice was given. Analysis of phase two revealed that patients were not consistently informed of any key postoperative messages. In phase 3 analysis, the proposed benchmarks were met in four out of six categories.

CONCLUSIONS

Postoperative advice after root canal treatment in the DDUH is both poorly recorded and inconsistently delivered. A combination of oral postoperative instructions and written postoperative advice provided the most effective delivery of patient information.

Release of bio-active dentine extracellular matrix components by histone deacetylase inhibitors (HDACi)

AIM

To characterize dentine matrix component (DMC) release and smear layer removal by histone deacetylase inhibitors (HDACis).

METHODOLOGY

DMCs were extracted from powdered human dentine over 14 days using three HDACis, valproic acid (VPA), trichostatin A (TSA) and suberoylanilide hydroxamic acid (SAHA) and compared with a control extractant, 10% (w/v) EDTA. Protein compositions of the resultant extracts were analysed by 1D-polyacrylamide gel electrophoresis (1D-PAGE), TGF-β-1 and MMP-9 ELISAs and a high-throughput growth factor antibody array. Dentine discs with a standardized smear layer were prepared from human molars and treated with EDTA (17% w/v), polyacrylic acid (PA) (20% v/v) and the experimental HDACis prior to analysis by scanning electron microscopy. Parametric ELISA data were analysed using one-way anova and Tukey's post hoc test, whilst nonparametric smear layer data were analysed by Kruskal-Wallis test and Mann-Whitney U-test (P < 0.05).

RESULTS

HDACis did not remove smear layer in the presence or absence of PA pre-treatment (P ≥ 0.478). 1D-PAGE analysis demonstrated different protein profiles for EDTA and HDACi extracts. All HDACi solutions released TGF-β-1 although less effectively than EDTA (P < 0.001), whilst MMP-9 was extracted in significantly higher concentration by EDTA and VPA compared with TSA (P < 0.012). Antibody array analysis demonstrated the ability of HDACis to extract a complex cocktail of established/novel growth factors from dentine, albeit significantly less efficiently than EDTA for certain cytokines (TGF-β-1, PDGF-AA, VEGF-A) and significantly more effectively for others (GDF-15, IGF-1, EGRF-1, NGFR, BDNF, SCF-R).

CONCLUSIONS

HDACi release a range of bioactive DMCs that could promote dentine repair processes in vivo; however, they are ineffective at removing smear layer.

Epigenetic modulation of dental pulp stem cells: implications for regenerative endodontics

Dental pulp stem cells (DPSCs) offer significant potential for use in regenerative endodontics, and therefore, identifying cellular regulators that control stem cell fate is critical to devising novel treatment strategies. Stem cell lineage commitment and differentiation are regulated by an intricate range of host and environmental factors of which epigenetic influence is considered vital. Epigenetic modification of DNA and DNA-associated histone proteins has been demonstrated to control cell phenotype and regulate the renewal and pluripotency of stem cell populations. The activities of the nuclear enzymes, histone deacetylases, are increasingly being recognized as potential targets for pharmacologically inducing stem cell differentiation and dedifferentiation. Depending on cell maturity and niche in vitro, low concentration histone deacetylase inhibitor (HDACi) application can promote dedifferentiation of several post-natal and mouse embryonic stem cell populations and conversely increase differentiation and accelerate mineralization in DPSC populations, whilst animal studies have shown an HDACi-induced increase in stem cell marker expression during organ regeneration. Notably, both HDAC and DNA methyltransferase inhibitors have also been demonstrated to dramatically increase the reprogramming of somatic cells to induced pluripotent stem cells (iPSCs) for use in regenerative therapeutic procedures. As the regulation of cell fate will likely remain the subject of intense future research activity, this review aims to describe the current knowledge relating to stem cell epigenetic modification, focusing on the role of HDACi on alteration of DPSC phenotype, whilst presenting the potential for therapeutic application as part of regenerative endodontic regimens.

Clinical decision-making after endodontic instrument fracture

When a file fractures during root canal treatment there are several treatment options available to the clinician. The definitive management should be based on a thorough knowledge of the success rates of each treatment option, balanced against potential risks of removal or file retention. Although integration of modern techniques into endodontic practice has improved the clinician's ability to remove fractured files, removal may not always be possible or even desirable. The aim of the third and final review in this series was to analyse the literature with regard to the management of fractured files. Analysis of the literature demonstrated that the presence of a fractured instrument need not reduce the prognosis if the case is well treated and there is no evidence of apical disease. Therefore, in cases without apical disease removal of the file may not be necessary and retention or bypass should be considered. If apical disease is present, file fracture significantly reduces prognosis indicating a greater need to attempt file removal or bypass. A plethora of different methods have been employed to remove fractured instruments and although successful, these techniques usually require the use of the operating microscope and specialist care. Removal of a fractured file is not without considerable risk, particularly in the apical regions of the root canal, therefore, leaving the fragment in situ should be considered if referral is not possible. Finally, it is imperative that the patient is informed (accompanied by appropriate record keeping) if instrument fracture occurs during treatment or if a fractured file is discovered during a routine radiographic examination.

Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial

AIM

To investigate the pulpal response to direct pulp capping in healthy human teeth with mineral trioxide aggregate (MTA) as against calcium hydroxide cement (Dycal) as control.

METHODOLOGY

Twenty healthy human third molars had iatrogenic pulpotomy and direct pulp capping with MTA. Another 13 teeth were capped with Dycal as controls. The teeth were restored, with IRM, clinically reviewed and extracted after a number of pre-determined intervals (1 week, 1 month and 3 months). The specimens were fixed, decalcified, subdivided axially into two halves in the oro-buccal (lingual-buccal) plane, embedded in plastic, serial sectioned and evaluated qualitatively and quantitatively by correlative light and transmission electron microscopy with appropriate statistical evaluation of the quantitative data.

RESULTS

Iatrogenic pulpal wounds treated with MTA were mostly free from inflammation after 1 week and became covered with a compact, hard tissue barrier of steadily increasing length and thickness within 3 months following capping. Control teeth treated with Dycal revealed distinctly less consistent formation of a hard tissue barrier that had numerous tunnel defects. The presence of pulpal inflammation up to the longest observation period (3 months) after capping, was a common feature in Dycal specimens.

CONCLUSIONS

The MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. Therefore, MTA or equivalent products should be the material of choice for direct pulp capping procedures instead of hard setting calcium hydroxide cements.

The potential association between smoking and endodontic disease

The aim of this review was to analyse the literature to assess the possibility of an association between smoking and endodontic disease and the prognosis of endodontically treated teeth. The review of the prognosis of endodontically treated teeth involved taking account of any potential associations with smoking and endodontic disease and marginal periodontitis, and smoking and prosthodontic outcomes. In addition, the role of smoking in implant failure and surgical wound healing was analysed with a view to drawing parallels regarding the possible implications of smoking on the outcome of surgical endodontics. A MEDLINE and Cochrane library search including smoking and various endodontic keyword searches identified three papers which discussed the variables, and did not just mention them separately in the text. The literature demonstrates a paucity of evidence relating smoking with endodontic disease and prognosis, but nevertheless presents evidence of a possible influence on the prognosis of endodontically treated teeth in smokers and a likely increase in surgical complications. The possible merits of a smoking cessation protocol prior to surgical endodontics are also discussed.

Selected reference aids for small medical libraries

This annotated list of 178 items is compiled as a guide to the development of the reference collection in a small medical library.Arrangement, following the pattern of the previous revision, is by broad subject groups. Titles are chiefly in English. Textbooks in subject fields have been omitted since these are covered adequately in several comprehensive guides to the literature.