How do we and how should we deal with uncertainty in endodontics?

Abstract

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. Whilst 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.

Pre‐medical assessment of root–canal–filled teeth with asymptomatic apical periodontitis—A multifaceted balancing act

“…One way to understand uncertainty in clinical decision‐making is to identify the source of uncertainty, and what the uncertainty pertains to, i.e., the issue of uncertainty (Han et al, 2011). Although the pre‐medical dental situation differs from the general dental situation, the work by Pigg et al (2022), where various aspects of uncertainty were applied to root–canal–filled teeth with AAP, may help understand the results of the present study. Much of the uncertainty expressed by the informants in our study relates to the unknown probability of apical exacerbation and infectious sequelae, the ambiguity regarding what to consider a focus of infection in the pre‐medical context and the increased complexity of risk‐assessment due to the underlying medical situation.…”

“…Yet, the scientific evidence is slim regarding the correlation between risk of apical flare‐up and time since root–canal treatment (Yu, Messer, Shen, et al, 2012; Yu, Messer, Yee, & Shen, 2012). Overall, studies on exacerbation of post‐endodontic apical lesions are scarce (Pigg et al, 2022; Yu, Messer, Shen, et al, 2012; Yu, Messer, Yee, & Shen, 2012), which renders the prediction of such events difficult. The same can be said regarding apical lesions in medically compromised patients.…”

“…In the present study, however, external uncertainty dominated. As this originates from a universal lack of knowledge as opposed to personal ignorance, it cannot be reduced through individual measures but needs to be accepted until the state of evidence improves (Pigg et al, 2022). Moreover, even with an increase of evidence on the general probability of apical exacerbation, uncertainty related to the development of an individual case will still remain.…”

The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review

“…Diagnosis in Endodontology can be a somewhat controversial subject, especially when it comes to decision making and a proper clinical attitude [1,2]. Reversible or irreversible pulpitis, cyst or periapical inflammation are the daily practice self-reflections of many clinicians [2,3].…”

“…Diagnosis in Endodontology can be a somewhat controversial subject, especially when it comes to decision making and a proper clinical attitude [1,2]. Reversible or irreversible pulpitis, cyst or periapical inflammation are the daily practice self-reflections of many clinicians [2,3]. Pulp diagnosis and periapical diagnosis are subject to interpretation, knowledge, experience, state of mind and other aspects that convert the assessment protocol into a personal perception [4].…”