UNCERTAINTY IN ENDODONTICS: STRATEGIES FOR

UNDERSTANDING AND MANAGEMENT

Uncertainty in Endodontics: Strategies for
Understanding and Management
Thesis for Doctoral Degree (Odont. Dr.)
By Joséphine Brodén

The thesis will be defended in public at the Auditorium, Faculty of Odontology,

Malmö, Sweden
Friday, December 9, 2022, at 9:15

Principal Supervisor
Associate professor Helena Fransson
Malmö University
Faculty of Odontology

Co-Supervisors
Associate professor Maria Pigg
Malmö University
Faculty of Odontology

Associate professor Thomas Davidson

Linköping University
Department of Health, Medicine and Caring Sciences

Opponent
Associate professor Sivakami Rethnam Haug
University of Bergen, Norway
Department of Clinical Dentistry

Examination Board
Associate professor Cecilia Christersson
Malmö University

Professor John Whitworth

Newcastle University, Great Britain
School of Dental Sciences

Professor Ulf Persson

The Swedish Institute for Health Economics
Malmö University, Faculty of Odontology
Doctoral Dissertation in Odontology 2022

Copyright holder Joséphine Brodén 2022

Copyright pp 5-69 Joséphine Brodén

Appendix © Wiley
Paper 1 © Mosher & Linder
Paper 2 © Taylor & Francis
Paper 3 © by the Authors (Manuscript unpublished)
Paper 4 © by the Authors (Manuscript unpublished)

ISBN 978-91-7877-312-1 (print)

ISBN 978-91-7877-311-4 (pdf)
DOI 10.24834/isbn.9789178773114
Print: Media-Tryck, Lund university, 2022
JOSEPHINE BRODÉN
UNCERTAINTY IN ENDODONTICS:
Strategies for Understanding and Management

Malmö University, 2022

Faculty of Odontology
Department of Endodontics
The publication is also available in electronic format at:
mau.diva-portal.org
Contents

ABBREVATIONS AND VOCABULARY ........................................ 9

ABSTRACT .............................................................................. 11

POPULÄRVETENSKAPLIG SAMMANFATTNING ...................... 13

PREFACE ................................................................................ 15

INTRODUCTION ...................................................................... 16
Uncertainty ......................................................................................... 16
Uncertainty regarding the assessment of a vital exposed pulp .... 19
Uncertainty regarding pulpectomy in young patients .................... 21
Uncertainty regarding root-filled teeth with persistent apical
periodontitis. .................................................................................. 22
Health economic evaluation and cost-effectiveness analysis ....... 23
Reducing uncertainty by modelling ............................................... 24
Research methods to study uncertain topics ................................ 25
Management of uncertainty in dental education ........................... 25
Managing uncertainty with reflective practice ............................... 26

AIMS ....................................................................................... 28

METHODS ............................................................................... 29
Study I - Systematic review ........................................................... 29
Study II - Health economic model ................................................. 30
Study III - Repeated questionnaire about awareness of and comfort
with uncertainty ............................................................................. 32
Study IV - Reflections about clinical experience ........................... 34
Statistical analysis ......................................................................... 36
Non-parametric test ....................................................................... 36
RESULTS ................................................................................. 37
The available evidence on pulp capping procedures compared to
root canal treatment in young permanent teeth ............................ 37
The comparison of the cost-effectiveness of pulp capping and root
canal treatment .............................................................................. 38
Answers to the questionnaire about awareness of and comfort with
uncertainty ..................................................................................... 39
Dental students’ reflections on clinical experience in relation to
uncertainty ..................................................................................... 43
Theme 1. The meaning of clinical experience............................... 43
Theme 2. Assumed differences regarding assessment ................ 44
Theme 3. Relating to the same risk factors................................... 44

DISCUSSION ........................................................................... 45
Main findings ................................................................................. 45
Quantitative or qualitative methods ............................................... 46
Study I - Systematic review ........................................................... 46
Study II - Health economic model ................................................. 48
Study III - Repeated questionnaire about awareness of and comfort
with uncertainty.............................................................................. 50
Study IV - Reflections on clinical experience ................................ 51
Clinical implications ....................................................................... 53
Statistical analysis ......................................................................... 53
Ethical considerations ................................................................... 53

CONCLUSIONS ........................................................................ 55
Suggestions for future research .................................................... 56

AUTHOR CONTRIBUTIONS ..................................................... 57

ACKNOWLEDGEMENTS .......................................................... 58

REFERENCES ......................................................................... 60

APPENDIX ............................................................................... 69
ABBREVATIONS AND VOCABULARY

AFP Annual Failure Probability

AFR Annual Failure Rate

Ca(OH)2 Calcium Hydroxide

ESE European Society of Endodontology

EVPI Expected Value of Perfect Information

ICER Incremental Cost-Effectiveness Ratio

MTA Mineral Trioxide Aggregate

SBU Swedish Agency for Health Technology Assessment and

Assessment of Social Services

STC Systematic Text Condensation

VOI Value of Information

VPT Vital Pulp Treatment

Apical Periodontitis Inflammatory lesion surrounding the tip of the root.

Exacerbation Acute worsening of an already existing chronic

inflammation.

Pulpectomy Root canal treatment of a vital tooth.

Systematic review Systematic search for and compilation of all relevant

literature addressing a specific research question.

9
 Vital pulp treatment Direct pulp capping class I and II
(after pulp exposure) Partial pulpotomy
Full pulpotomy

Sources of uncertainty Ambiguity: Uncertainty caused by

(Han et al. 2011) lack of reliability, credibility, or
adequacy of information about a
phenomenon.

Complexity: Uncertainty caused by

multiple interpretations or due to
interacting factors that have not been
properly studied.

Probability: Uncertainty caused by the

indeterminacy of a future event.

Uncertainty in modelling Parameter uncertainty: Lack of

knowledge about the values in a model.

Model uncertainty: Uncertainty about

the theory on which the model is based
on.

Variability (Stochastic uncertainty): A

random variation in outcome between
identical patients.

Comfort with uncertainty Feeling confident in one’s

capability to act or refrain from acting.

10
ABSTRACT

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

11
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.

12
POPULÄRVETENSKAPLIG
SAMMANFATTNING

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

13
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.

14
PREFACE

This thesis is based on the following studies, referred to by their roman

numerals in the text.

Study I
Brodén J, Heimdal H, Josefsson O, Fransson H. Pulp capping procedures versus
root canal treatment in young permanent teeth with pulp exposures due to caries.
A systematic review. Am J Dent. 2016; 29: 201–207.

Study II
Brodén J, Davidson T, Fransson H. Cost-effectiveness of pulp capping and root
canal treatment of young permanent teeth. Acta Odontol Scand. 2019; 7: 275–
281.

Study III
Brodén J, Fransson H, Vareman N, the Foresight Research Consortium,
EndoReCo, Pigg M. Reflection to enhance students´ awareness of and comfort
with uncertainty. Submitted.

Study IV
Brodén J, Pigg M, Vareman N, The Foresight Research Consortium, Fransson H.
What is the relationship between certainty and experience? A qualitative study
on dental students’ reflections on risk assessment of root-filled teeth. To be
submitted.

15
INTRODUCTION

Uncertainty
All research strives to seek knowledge and thereby reduce uncertainty. By
systematizing existing evidence, as is the practice of evidence-based medicine,
the best available evidence is summarized to reduce uncertainty. The knowledge
gaps that create uncertainty are revealed when areas with insufficient evidence
are identified (Straus et al. 2018). Two such knowledge gaps concern pulp
capping and pulpectomy in vital teeth with pulp exposure due to caries (SBU1,2
2011).
The source of uncertainty creating a knowledge gap can differ. Uncertainty often
occurs when the probability of a future event is unknown. Another source of
uncertainty is ambiguity, which can occur because of conflicting evidence or lack
of precise information. Complexity, a third source of uncertainty, results from
those aspects of a phenomenon that make it difficult to understand, for example
multiple interpretations or improperly studied interacting factors. Some types of
uncertainty can be reduced by adding information, while other types need to be
tolerated (Han et al. 2011).
The management of uncertainty can broadly be divided into two strategies:
reducing uncertainty and tolerating uncertainty. Often a combination of both is
used; more information is added until a threshold is reached, and a treatment
decision must be made. The information can come from different sources, for
example from scientific studies or from additional diagnostics. Clinical
inexperience leads to more discomfort with uncertainty which can in turn lead to
more diagnostic testing to reduce uncertainty (Stojan et al. 2022). Absolute
certainty in diagnosis is very seldom possible and too many tests trying to reduce

16
uncertainty can cause patients more harm than benefit and lead to a higher cost
for the patient or society (Kassirer 1989). Students need to understand if the
uncertainty comes from scientific knowledge gaps or personal ignorance, which
can be a difficult distinction for an inexperienced clinician (Fox 1957). Reflection
about the students’ own skills and knowledge should be encouraged in their
endodontic clinical training (De Moor et al. 2013). This can help unexperienced
clinicians to learn how to make decisions under uncertain conditions (Schön
1987).
This thesis has a twofold focus (Figure 1). Study I and II focus on reducing
uncertainty by systemizing evidence and using it to calculate cost-effectiveness
while Study III and IV focus on training dental students in understanding,
acknowledging and tolerating uncertainty.

17
 Endodontic
condition which Some examples of uncertainty
requires a when assessing risk and Issue studied in the
treatment decision making treatment decisions thesis

Study I

Assessing the probability of

Success rate of pulp
treatment failure and future
capping and root canal
pain
Vital pulp exposed treatment
by caries in
Assessing the risk of tooth
permanent tooth in
extraction Study II
child or adolescent
Choosing a cost-effective Cost-effectiveness of
treatment pulp capping and root
canal treatment

Study III

Dental students'
Determining whether a awareness of and
radiolucency is present comfort with uncertainty
Root-filled tooth when assessing the risk
with persistent Assessing the probability of for exacerbation
apical periodontitis exacerbation of apical
periodontitis
Study IV
Deciding whether to perform a
retreatment or wait and see The connection
between experience
and uncertainty when
making risk assessment

Figure 1. As in all scientific areas, uncertainty is present in many different aspects of the endodontic
treatment. Some aspects are approached in this thesis.

18
Uncertainty regarding the assessment of a vital exposed pulp
When a vital pulp is exposed, there are two different treatment concepts:
preserving the pulp vitality by performing a vital pulp treatment including direct
pulp capping, a partial pulpotomy or a full pulpotomy or removing the pulp tissue
and replacing it with root filling material by performing a pulpectomy (root canal
treatment of a vital pulp), see Figure 2. The dentist, together with the patient or
the patient’s guardian, needs to decide on which treatment concept to choose. The
goal is to ensure the tooth remains in function and keep the tooth free from
inflammation and infection as well as keep the patient free from pain. The criteria
for successful treatment of a vital pulp can be defined as absence of symptoms
and maintenance of pulp vitality (Duncan et al. 2019) while the criteria for a
successful root canal treatment have traditionally been the absence of pain and
signs of inflammations and healthy periodontal ligament or healing of periodontal
ligament on radiographic examination (Azarpazhooh et al. 2022). However, since
a patient can experience a root canal treatment as successful if a tooth is
asymptomatic and well-functioning, regardless of the presence of periapical
destruction, tooth survival can also be used as the outcome measure (Friedman &
Mor 2004, Kirkevang et al. 2022). Recently, tooth survival, which is a patient
reported outcome measure, has been identified by the the European Society of
Endodontology (ESE) as the most critical outcome measure to assess the
effectiveness of endodontic treatment (Duncan et al. 2021).

Direct pulp capping

Class I- Following trauma
Pulpectomy
Class II- Following deep
Partial Full (vital extirpation)
caries
pulpotomy pulpotomy and root filling

Figure 2.Treatment options according to the definitions by the ESE for a permanent tooth with
exposed vital pulp.

19
The success of vital pulp treatment seems to depend on the inflammatory state of
the pulp, and different success rates have been presented if the pulp has been
exposed by mechanical exposure through hard dentine or by caries. Studies on
pulp capping in teeth with pulp exposure due to mechanical exposure or trauma
have reported high success rates (Al-Hiyasat et al. 2006, Cvek 1978) and direct
pulp capping is the treatment recommended by the ESE in these cases. However,
the results after a vital pulp treatment in teeth with pulp exposure due to caries
have been considered less predictable, and there are gaps in the scientific
knowledge (Duncan 2022).
The uncertainty regarding the treatment choice is reflected in the differences
found in the recommendations of two leading endodontic societies. The ESE
recommend selective caries removal in teeth with reversible pulpitis to avoid pulp
exposure. In the case of pulp exposure during caries removal, pulp capping class
II or partial pulpotomy is recommended provided that the caries removal in deep
caries lesions was performed under aseptic conditions. If this was not the case,
pulpectomy is recommended in teeth with symptoms indicative of irreversible
pulpitis. Full pulpotomy may also be conducted in cases where there is partial
irreversible pulpitis in the coronal pulp, but it is emphasized that further studies
are needed (Duncan et al. 2019). In contrast, the American Association of
Endodontists (AAE) recommend complete removal of caries tissue and urge the
dentist to focus on removing all demineralized infected dentin and not on
avoiding pulp exposure. In the case of pulp exposure, the AAE does not specify
which vital pulp therapy to conduct but recommend considering one, even in
cases with symptomatic pulps, after evaluating hemorrhage control and clinical
tissue appearance with direct visualization (AAE 2021).
The success rate of pulp capping in teeth with pulp exposure due to caries varies
between studies. Various factors have been suggested as impacting the success
rate, for example, the use of rubber dam and the material used for the pulp
capping, but the evidence is unclear (Bjørndal et al. 2019). In some studies, where
pulp capping was performed with Ca(OH)2 by dental students and general
dentists, the 5-year success rates were under 40% (Barthel et al. 2000, Bjørndal
et al. 2010). In one of these studies, the majority of the treatments failed because
of pain leading to endodontic emergency treatments before the scheduled follow-
up appointment (Bjørndal et al. 2010). Other studies on pulp capping conducted
in a specialist setting and on teeth with pulp exposure due to caries show higher
success rates when using mineral trioxide aggregate (MTA) as the pulp capping
material. Studies using MTA have reported success rates above 80% at follow-

20
up (Bogen et al. 2008, Mente et al. 2014). Moreover, some clinical studies
comparing the materials Ca(OH)2 and MTA have reported an increased risk of
failure when using Ca(OH)2 (Mente et al. 2014, Kundzina et al. 2017). While a
systematic review comparing the two materials found no difference at follow-up
after 6 months, but after 12 months, MTA outperformed Ca(OH)2 (Cushley et al.
2021).
Conspicuous bleeding from the pulp and extremely deep caries are other clinical
indicator linked to treatment failure in teeth with pulp exposure (Matsuo et al.
1996, Careddu & Duncan 2021). Furthermore, a higher chance of successful
outcome after VPT has been reported for teeth with open apices compared to teeth
with closed apices (Aguilar & Linsuwanont 2011). In terms of age, conflicting
results have been reported where some studies have reported a better outcome for
younger patients (Bjørndal et al. 2010, Cho et al. 2013) with others reporting no
difference in outcome related to the patient’s age (Elmsmari et al. 2019). It may
be that better results can be expected after performing pulp capping in children
and adolescents compared to adults.
The inflammatory state of the pulp has traditionally been assessed based on the
patient’s history of pain combined with results from clinical examinations and
diagnostic tests (vitality and percussion tests). Unfortunately, since it is
impossible to assess whether the pulpitis is reversible with these tests, it cannot
be determined with high certainty when a vital pulp treatment is no longer
possible and the vital pulp should be removed and root canal treatment conducted
(Mejàre et al. 2012, Pigg et al. 2021, Donnermeyer et al. 2022).

Uncertainty regarding pulpectomy in young patients

Studies on root canal treatment in vital teeth in populations that include adults
show high success rates, above 90% (Ng et al. 2011, Gesi et al. 2006).
Prospective studies on pulpectomy in permanent teeth in children and adolescents
are rare. Retrospective studies in this group have reported apical periodontitis
associated with 25–52% of the root-filled teeth (Ridell et al. 2006, Jordal et al.
2014) and the calculated 5-year survival probability for root-filled teeth among
children is estimated to be 69% for children of age 6–18 and 46% for children of
age 6–11 (Bufersen et al. 2021). Root canal treatment in young permanent teeth
is a difficult task for the dentists and can be a challenge for young patients due to
the time-consuming treatment procedure. This can result in a poor quality of the
root filling (Ridell et al. 2006). A patient with a root filling of poor technical
quality is potentially at risk of developing apical periodontitis in the future, which

21
can in turn lead to pain and discomfort for the patient and a cost for society.
Studies also show that for molar teeth there is a risk for extraction before the
completion of the root canal treatment (Wigsten et al. 2021) and that root-filled
teeth are in general more commonly extracted than non-root-filled teeth
(Eckerbom et al. 1992).

Uncertainty regarding root-filled teeth with persistent apical

periodontitis.
In persistent apical periodontitis in root-filled teeth, there are various issues
related to uncertainty, see Appendix Figure 1.
The aim with the root canal treatment of a necrotic tooth where bacteria are
present in the root canal space is to remove as much as possible of the bacteria
and bacterial antigens and toxins responsible for inducing the immune response.
This will change the environment so that the remaining bacteria are unable to
spread and resolve the inflammation in the periapical tissue, which will allow the
periapical lesion to heal by repair or regeneration, or a combination of both. Some
studies indicate that systemic diseases such as cardiovascular diseases,
osteoporosis, diabetes mellitus and inflammatory bowel disease can have a
negative effect on the healing of apical periodontitis (Segura-Egea et al. 2022)
but there is no robust evidence of a causal relation. To be a proven causal relation
between two diseases, one disease must be proved to contribute to the
development of the other and when one disease is removed the frequency of the
other should be reduced (Segura-Egea et al. 2019). As these criteria remain
unfulfilled, there is currently no strong evidence of an existing causal relation
between apical periodontitis and any systemic disease.
If apical periodontitis fails to heal after root canal treatment, the tooth can be
retreated by removal of the old root filling material and additional disinfection of
the root canal space before a new root filling is placed. A root-filled tooth can
also be retreated through apical surgery, in which the root canal space is obturated
from the tip of the root. This will enclose the remaining bacteria in the root and
allow the apical periodontitis to heal. Another more radical way to treat apical
periodontitis is by extracting the tooth.
Apical periodontitis in previously root-filled teeth is often diagnosed in
radiographs. In a Swedish epidemiologic study from Jönköping, 34% of all root-
filled teeth and 46% of root-filled molars were diagnosed with apical
periodontitis (Silnovic et al. 2022). For root-filled teeth with persistent

22
asymptomatic apical periodontitis there is likely a low probability of
exacerbation, but this has not been extensively studied. In one study, where adult
patients with periapical radiolucency in root-filled teeth were invited to attend a
recall up to 20 years after treatment, the incidence of painful flare ups was 5.8%,
defined as when the patient records revealed that the patient had required an
unscheduled dental visit because of symptoms from the tooth (Yu et al. 2012).
Apical periodontitis before treatment has been reported as the most predictive
factor for apical periodontitis post treatment in root-filled teeth (Kirkevang et al.
2017). The probability of severe infections after endodontic treatment is
unknown. In a retrospective study on 60 patients requiring hospital care because
of odontogenic maxillofacial abscesses, due to periapical infection, 12% of those
teeth responsible for the infection had completed root canal treatments and 27%
had unfinished root canal treatments (Grönholm et al. 2013).

Health economic evaluation and cost-effectiveness analysis

The resources a society can spend on healthcare are limited and it is therefore
important to spend these limited resources as wisely as possible. Health economic
evaluations are about identifying, measuring, valuing and comparing costs and
consequences of different alternatives.
Before implementing new treatment methods, it should be investigated whether
they provide good value for money. Even if a treatment is effective, it does not
automatically follow that it is cost-effective. A cost-effectiveness analysis will
add information about whether a treatment or health care program is cost-
effective by trying to capture all costs and effects involved.
First the direct and indirect costs to be included in the analysis should be
identified. Depending on the viewpoint of the analysis, different costs can be
included. From the patient’s viewpoint, travel cost and lost income are relevant,
but this may not be as interesting from the care provider’s perspective. Data on
cost can be collected prospectively, for example, from questionnaires completed
by patients, or estimated retrospectively from patient records or data systems. The
data could, for example, include cost for the treatment, the time used by the
dentist and overhead costs (Drummond et al. 2005).
The effects should be measured the same way for all alternative treatments to
enable comparison. The results are presented as the Incremental Cost-
Effectiveness Ratio (ICER) and ICER is calculated by dividing the difference in
effect between the treatment methods with the difference in cost (Schwendicke

23
& Herbst 2022). The outcome measures could be tooth survival or absence of
pain. If, for example, the outcome measure is tooth survival, the ICER can then
be expressed as 100 Euro per avoided tooth extraction, which means that one
avoided extraction could be bought for a price of 100 Euros.

Reducing uncertainty by modelling

Health economic modelling is a systematic approach used in health economic
evaluations to reduce uncertainty and to create more information before decision
making. By using a model for the cost-effectiveness analysis, the treatments to
be compared can be extrapolated over time. Simulation models can also be used
trying to resemble reality and analyze future possible scenarios (Briggs et al.
2006).
One type of model is a Markov model where health states are defined, and a
cohort of identical simulated individuals either stay in one health state or move
between different health states. The individuals can only be in one health state at
a time. Data on the probability of individuals transitioning between health states
is identified and the probability that a simulated patient will transition between
health states in the model is calculated from this scientific data.
The uncertainty that the health economic model tries to capture can be categorised
as parameter uncertainty (lack of knowledge about the values in the model, for
example the probability of transitioning between health states) and model
uncertainty (uncertainty about the theory on which it is based). These sources of
uncertainty will impact the certainty of the results. Briggs et al. distinguish
between two other relevant concepts related to uncertainty in decision modelling
namely variability “differences that occur between patients by chance” and
heterogeneity “the differences that occur between patients that can be
explained”. Heterogeneity relates to an explainable difference and is therefore
not a source of uncertainty (Briggs et al. 2006).
Variability is considered in all decision models. For example, pulp capping will
be successful in some patients and result in pulp necrosis in other, and this is
expressed as a probability in the model. The decision model is based on the
likelihood of all the consequences of the treatments included in the model, and
these are all expressed as probabilities. Each consequence has a cost and an
outcome. The purpose with a model is to answer a question about resource
allocation (Briggs et al. 2006), such as; what is the cost-effective treatment for a
young individual with a permanent tooth with pulp exposure due to caries?

24
Schwendicke & Stolpe (2014) constructed a Markov model based on a 20-year-
old male in a German setting where pulp capping was found to be cost-effective
in younger patients and root canal treatment cost-effective in older patients. Since
the outcome of pulp capping and root canal treatment might differ between adults,
and adolescents and children, the results derived from an adult-based model
cannot be transmitted directly to children.

Research methods to study uncertain topics

The most appropriate research method should be selected dependent on the
research questions and the aim of the study. Quantitative methods are, for
example, useful for answering questions about effectiveness, frequencies, and
quantities, whereas qualitative methods are more appropriate when the aim is to
understand a phenomenon. When there is uncertainty surrounding a new or not
well studied phenomenon, qualitative methods are useful for gaining
understanding and creating hypotheses. Sometimes a qualitative study can add
knowledge before conducting a quantitative study since a topic needs to be
sufficiently well known in order to formulate a clear hypothesis, which can then
be studied using statistical hypothesis testing (Malterud 2009).
Quantitative and qualitative methods could also be combined using mixed
methods to gain a broader and deeper understanding of a phenomenon. There are
various designs of mixed methods where quantitative and qualitative data are
collected separately and the results are brought together and combined, or where
quantitative or qualitative data are collected first and then followed by another
method. Quantitative data could be collected first followed by a qualitative
method used to explain the results or qualitative data could be collected first and
used to design a quantitative component. What these designs all have in common,
however, is that more insight is gained by combining the results (Creswell 2015).

Management of uncertainty in dental education

During dental education the students will start as novices with the goal to
eventually become competent dentists. Novices are taught to make decisions
following a set of rules. The rules are followed regardless of the situation and the
students learn not to violate the rules even if an uncertain situation would require
so. Therefore, it is difficult for a novice to deal with uncertain situations.
Eventually when gaining more experience and becoming advanced beginners the
students will learn how to make decisions learning from experience and not only
by applying rules (Dreyfus & Dreyfus 1986). Helping students facing the

25
challenges of making judgements under uncertainty is one of the key roles for
dental educators. As competent dentists, the former students will have to choose
between treatment concepts despite feeling uncertain. Studies have suggested that
younger dentists are less invasive when removing carious tissue compared to
older colleagues and that the opinion of peers have an impact on their caries
removing strategy (Schwendicke & Göstemeyer 2016). For the decision to
perform vital pulp treatment or a root canal treatment, studies have demonstrated
a lack of consensus among dentists (Careddu et al. 2021, Crespo-Gallardo et al.
2018, Croft et al. 2019, Frisk et al. 2013, Stangvaltaite et al. 2017). The same
lack of consensus appears to apply to the decision on how to manage post-
treatment disease in root-filled teeth (Rawski et al. 2003, Kvist et al. 2004). Due
to the lack of consensus within the dental profession, it seems difficult to rely on
the opinions of peers; instead, dentists must be able to make safe and constructive
treatment decisions despite remaining uncertain.
Studies investigating medical clinicians working with emergency treatments
show that the way a clinician chooses to manage a patient can be explained both
by how tolerant they are of uncertainty and by how much experience they have
(Lawton et al. 2019). In medical research, there has been an increase in studies
on uncertainty and tolerance for uncertainty (Strout et al. 2018), but the subject
has received very little attention in dentistry. There are even those who claim that
there is a harmful culture of certainty in dentistry and dental education (von
Bergmann & Shuler 2019). Teaching dental students, a constructive response
towards uncertainty is thus important since studies indicate that medical
professionals with a low tolerance of uncertainty are more likely to order
additional diagnostic tests which could lead to overtreatment. Moreover, they are
also at a higher risk of negative health effects such as stress and burnout (Strout
et al. 2018).

Managing uncertainty with reflective practice

One way of teaching students a constructive response towards uncertainty is to
teach them to become reflective practitioners. Reflection can help professionals
dealing with uncertain situations where there are no standard procedures and no
right answers (Schön 1987). Ryan and Ryan (2012) differentiate between
personal reflection and academic or professional reflection. Personal reflection is
not necessarily conscious or has a clear goal and does not always reach a critical
level. On the contrary, professional reflection helps learners to understand their
experience and ultimately helps to improve future experience.

26
Reflection can also be divided into “reflection in action” and “reflection on
action” where the first refers to when, in the middle of the action we consciously
think about what we are doing. By starting to reflect on things we do, as we do
them, we can see them from new angles and the reflection can change what we
do. Reflection on action is the reflection that occurs when we are thinking back
on something we just did (Schön 1987).
Reflective practice has been introduced in different areas in dental education, for
example, in the form of reflective diaries in connection to clinical placements
(Jonas-Dwyer et al. 2013), briefing sessions before clinical practice and
debriefing sessions after clinical practice (Botelho & Bhuyan 2021) as well as
written reflections after seeing video recordings of students treating pediatric
patients (Khanna et al. 2020). A qualitative study involving medical students in
Finland reported that reflection was effective in expressing and managing
uncertainty (Nevalainen et al. 2010). Corresponding studies involving dental
students are lacking; nevertheless, reflection is important at the undergraduate
level and throughout professional life (Schön 1987) as well as in research.
Knowledge through research can be described as the result of systematic critical
reflection, where the researcher places data and interpretations in a larger context.
When the research is published, other researchers can contribute with critical
reflection from new angles (Malterud & Midenstrand 2009).

27
AIMS

The main objectives of the thesis are to contribute with information that reduces
uncertainty regarding the treatment of cariously exposed pulps in young
permanent teeth and examine students’ perceptions of and attitudes towards
uncertainty, with the ultimate goal of improving dental education to ensure that
future students will manage well despite uncertainty.
The following illustrates the aim for each study:
Study I
To evaluate the available evidence on pulp capping procedures and root canal
treatment in young permanent teeth with vital pulps exposed by caries by means
of a systematic review.
Study II
To compare the cost-effectiveness of pulp capping and root canal treatment of
posterior permanent vital teeth in children and adolescents with pulp exposures
due to caries.
Study III
To develop and test a reflection exercise with written reflections based on
prompts from an established model and to investigate if the reflection exercise
would make a group of students more aware of and comfortable with uncertainty
while conducting risk assessment.
Study IV
To explore how dental students reflected on clinical experience in relation to
uncertainty when assessing the risk for exacerbation of apical periodontitis in
root-filled teeth.

28
METHODS

Study I - Systematic review

To reduce the uncertainty regarding treatment of young permanent teeth with
vital pulps exposed due to caries, a systematic review was conducted using three
databases: PubMed (National Center for Biotechnology Information, U.S.
National Library of Medicine) Web of Knowledge (Web of Science, Thompson
Reuters) and The Cochrane Library (John Wiley & Sons, Ltd).
The research question was structured according to PICO (Straus 2011)
(Population, Intervention, Control, Outcome): In children and adolescents with
cariously exposed permanent teeth (P), is pulp capping (I) more beneficial than
root canal treatment (C) in achieving a symptom free tooth with normal periapical
conditions (O)?
Separate searches were conducted for pulp capping procedures and root canal
treatments in young permanent vital teeth (Table 1). The database searches were
performed between September and November 2013. The identified studies about
root canal treatment went through an initial screening and were sorted after
reading the title, and only for the publications considered relevant in terms of the
inclusion and exclusion criteria were the abstracts read. All abstracts of the
identified studies about pulp capping procedures were read, along with the
selected abstracts about root canal treatment.
The inclusion criteria for both treatment methods included human patients aged
20 years or under at the date of intervention and permanent vital teeth with
cariously exposed pulps. A pulp capping procedure (direct pulp capping or partial
pulpotomy) or pulp extirpation and root canal obturation should have been
described, and after root canal treatment, the outcome should have been evaluated

29
with radiographic examination. Moreover, after a pulp capping procedure the
outcome should have been evaluated by radiographic examination and/or
sensitivity testing. The presence or absence of clinical symptoms such as pain on
percussion, sinus tract, abscess formation should also have been reported, and the
study needed to have been prospective with a follow-up of at least 1 year.
Abstracts meeting the inclusion criteria were retrieved in full text. The full text
studies that did not meet the inclusion criteria were excluded.
The reference lists of the included studies were searched for additional studies. If
the authors disagreed, consensus was reached by discussion. The GRADE
guidelines were used to determine the quality of evidence in answering the
research question (Balshem et al. 2011).

Table 1.
Search strategies in PubMed.

Intervention Search strategies

(studies published between 1 January 1900 and 31
December 2012)

Root canal treatment (in children # 1. Root Canal Treatment

and adolescents with cariously
exposed permanent teeth)
# 2. Root Canal Therapy
# 3. Endodontic Treatment
# 4. Pulpectomy
# 5. Permanent
# 6. Case Reports [MeSH]

#1 OR #2 OR #3 OR #4 AND #5 NOT #6

Pulp capping procedures (in children # 1.”Partial pulpotomy”

and adolescents with cariously
exposed permanent teeth)
# 2. Pulp Capping
# 3. (cap OR capp*)
# 4. (carie* OR cario* OR decay*)
# 5. Permanent
# 6. “Case Reports”

#1 OR #2 OR #3 AND #4 AND #5 NOT #6

Study II - Health economic model

In Study II, to reduce uncertainty when making a treatment decision between a
pulp capping procedure and a root canal treatment, data on treatment success from
the findings in Study I were used together with other relevant available data to
calculate the cost-effectiveness, illustrated in Figure 3.

30
 Tooth with
pulp Tooth
capping extracted

Pulp exposure
due to caries

Root-filled Patient
tooth death

Figure 3.
The starting point of the state transition diagram was a 12-year-old child with a pulp exposure due to
deep caries in a vital permanent first molar. The patient could transition to another health state once
a year. The patient started in one of the health states "Tooth with pulp capping" or “Root-filled
tooth”. Adapted from Study II, Figure 1.

For the cost-effectiveness analysis, a Markov model was created in Excel

(Microsoft Excel 2016MSO (16.0.10325.20036) 64-bit version) where a
simulated cohort of 1000 patients was followed for 9 years, until the cohort
reached the age of 21. The simulated patients would start with a pulp capping or
a root canal treatment after pulp exposure due to caries. The probability that the
patients would transition to another health state was based on the best available
data on the success and failure of different treatments and the data on mortality
for the age group. This data on the annual failure rates (AFR) were used to
calculate the annual failure probabilities (AFP), (Table 2). The AFP was assumed
to be constant for the entire follow-up period. Data on cost was retrieved from
the reference prices settled by the Dental and Pharmaceutical Benefits Agency
(for details on cost data see Study II, Table 3). The cost was discounted by 3%
annually. Sensitivity analyses were performed to handle the uncertainty in the
model by changing some parameters and analyzing the effect on the results.
Higher annual failure probability for pulp capping was analyzed, AFP 0.05 and

31
0.2., where 0.2 was seen as a worst-case scenario. An analysis was also performed
where the costs were discounted at 0% or 5%.

Table 2.
The yearly probability of transtitioning (annual failure probability, AFP) to another health state after
initial treatment. The probabilities are based on the annual failure rates (AFR) from data in the
literature. The table has been altered for the thesis. The original table is found in Study II.

Initial treatment Annual Failure Health state or Source for data on Annual
Probability additional Failure Rates
treatment
Pulp capping 0.03 Root-filled tooth Study I
Bjørndal et al. 2017
Barthel et al. 2000

0.004 Tooth Extracted Study I

Bjørndal et al. 2017
Barthel et al. 2000

0.016 New composite Pallesen et al. 2013

filling

Root canal 0.0048 New root canal Dawson et al. 2017

treatment treatment
(retreatment)
0.018 Tooth extracted Fransson et al. 2016
(unpublished data)
0.07 New composite Dawson et al. 2017
filling

Study III - Repeated questionnaire about awareness of and comfort

with uncertainty
In a group of final-year dental students at Malmö university, a repeated
questionnaire was used to examine if a reflection exercise affected the student’s
awareness of and comfort with uncertainty. The reflection exercise and control
exercise were conducted in connection with the course evaluations in the end of
the students’ penultimate and final semesters. They were mandatory for the 52
students but participation in the study was voluntary, and 51 students agreed to
participate. One additional student joined the course during the final semester and
participated in writing the reflections, thus these reflections were also included in
the analysis in Study IV, rendering 51 results for analysis in Study III and 52
reflections for analysis in Study IV.
The students were presented a case with a root-filled tooth with a large restoration
and a diffuse widening of the periodontal ligament space. They were asked to

32
complete a questionnaire about certainty and comfort related to assessing the risk
for exacerbation of apical periodontitis in the case (Table 3). The answers were
on a 5-point Likert-type scale, ranging from very certain/comfortable to very
uncertain/uncomfortable.
In the first question, the students were asked to estimate the risk for exacerbation
in the case. The following six questions were about certainty/uncertainty and
comfort/discomfort. The students were randomized to either a reflection exercise
or a control exercise. In January, the students in Group A participated in the
reflection exercise and the students in Group B in the control exercise. After the
exercises they were asked to complete the same questionnaire again. The session
was repeated after five months, and in June, the students in Group A participated
in the control exercise and the students in Group B participated in the reflection
exercise.

Table 3.
The six questions in the questionnaire, translated from Swedish. Answers were on a 5-point Likert-
type scale ranging from very certain/comfortable to very uncertain/uncomfortable.

Number Question Topic

1 How certain do you feel about your assessment of the Feelings of certainty or
probability of the patient experiencing an exacerbation uncertainty
of apical periodontitis within 4 years?

2 How certain do you feel about your own capacity to Feelings of certainty or
handle this case? uncertainty

3 How comfortable are you with your ability to handle the Comfort or discomfort
situation and do your best for the patient? with uncertainty

4 How certain do you think an experienced colleague Perceiving limitations in

would feel about assessing the probability of one’s own knowledge
exacerbation of apical periodontitis within 4 years? (Ilgen et al. 2019)

5 How certain do you feel that what you see on the Recognizing the
radiograph is a sign of disease? situation as ambiguous
(Ilgen et al. 2019)
6 If you had access to more information about the patient Recognizing the
(such as additional radiographs or examination information as
findings, and relevant literature on the subject), how incomplete (Ilgen et al.
certain would you then feel about assessing the 2019)
probability of the patient experiencing an exacerbation
of apical periodontitis within 4 years?

33
In the reflection exercise, the students were given prompts for writing reflections
adapted from Ryan & Ryan (2012) constructed to stimulate stepwise deeper
reflections (Table 4) and were asked to reflect on assessing the risk for
exacerbation of apical periodontitis in the case with the root-filled tooth. The
control exercise, a quiz comprising 13 multiple-choice questions (MCQ), was
constructed not to stimulate reflection. In a second session five months later, the
groups changed exercises in a crossover fashion so that in the end, all students
had participated in both exercises. For details of the flow, see Study III, Figure 1.
As in the first session, they were also asked to complete the questionnaire (Table
3) before and after the exercises. The answers to the questionnaire before and
after the reflection exercises and the control exercise were compared to see if the
reflection exercise had an effect on the students’ feelings of uncertainty and
comfort with uncertainty.

Study IV - Reflections about clinical experience

The written data from the reflections were organized and summarized using
Systematic Text Condensation (STC) according to Malterud (2012). The first step
in the analysis of the reflections was to read through all text, gain an overall
impression and identify preliminary themes. After reading through all text, the
authors agreed that the reflections on the first five prompts, in the categories
Report & respond, Relate and Reason (Table 4) focused mostly on strategies to
manage a perceived lack of information and did not warrant further analysis. In
contrast, the reflections about how an expert would reason, how the reasoning
could differ from a student’s, and in some cases about over and under treatment
and changing strategies if proved wrong, evoked interest about the students
thoughts on experience and its relation to certainty. Therefore, the data for the
further steps in the systematic text condensation constituted of reflections on
prompts 6 and 7 (Table 4), and the analysis focused on understanding how the
students reflected on experience and its relation to certainty.
The next steps in the analysis were to classify and sort meaning units in the text
and categorize them under each preliminary theme. When the meaning units were
categorized, the themes were elaborated and subgroups were described. The
meaning units from each subgroup were used to create artificial quotations which
were used to describe the content. Representative citations illustrating the
different subgroups with the students’ own words were chosen from the text.
Finally, the original text was read again, and it was validated that the descriptions
and the quotations reflected the original context.

34
Table 4.
Prompts adapted from the 4R of reflection (Ryan & Ryan 2012) and levels of reflection according to
the 4Rs.

Number Prompts Levels of reflection

1 What is the case about? Describe the case from a Report & respond
biological point of view.

2 What strategy do you have when assessing the Report & respond
probability for exacerbation of apical periodontitis in
this case?

3 What knowledge do you have about assessing the Relate

probability of exacerbation of apical periodontitis in a
case like this? Think of a similar case that you have
read about or encountered before. Is there any
factor that is different in this case that could indicate
a different biological condition? Explain!

4 What are the risks for the patient? What do you Relate
really know about the risk? What do you need to
know more about? Explain!

5 Think through the biological process, based on Reason

theory, and fill in keywords describing biological
factors from a leaking restoration to the exacerbation
of apical periodontitis.

6 How do you think an expert would reason about the Reason

patient's condition and assess the risk? Is it different
from your way of reasoning?

7 If your chosen strategy turns out to be wrong – it Reconstruct

could mean that you either overtreated the patient,
i.e., that you treated a condition that did not require
treatment, or neglected to treat a condition that
required treatment, i.e., undertreatment. Think about
what is best from the perspective of efficient
utilization of resources and from the ethical
perspective. Reflect on what could make you change
strategy.

35
Statistical analysis
The statistical analysis in Study III was performed using IBM SPSS Statistics
version 25.0 (SPSS Inc, Chicago, IL, USA). Descriptive statistics were used to
describe the frequency of the answers at different times, namely the 1st (baseline),
2nd, 3rd and 4th times.
Non-parametric test
Mann-Whitney U-tests were performed to identify differences in the answers to
the questionnaire between the two groups (Group A and Group B), i.e., the
students participating in the reflection exercise in January and in June. Separate
tests were performed comparing the answers from the questionnaire the 1st, 2nd,
3rd and 4th times.
Further, Wilcoxon signed rank tests were performed to identify changes in the
responses to the questionnaire within the groups from the 1st time to the 2nd time,
from the 2nd time to the 3rd time, and from the 3rd time to the 4th time.

36
RESULTS

The available evidence on pulp capping procedures compared to root

canal treatment in young permanent teeth
In the systematic review, ten studies were identified and information on the
treatment of 299 permanent teeth from patients under age 20 were retrieved.
Among these teeth, 201 were treated by partial pulpotomy (involving removal of
pulp tissue prior to capping), with a follow-up between 1 and 11.7 years, and 98
teeth were treated by direct pulp capping with a follow-up between 1 and 9 years.
The success rates concerning the outcome “symptom free tooth with normal
periapical conditions”, were slightly higher for partial pulpotomy, compared to
direct pulp capping (Table 5). The quality was rated as low in all studies since
they all lacked a control group relevant for this systematic review. No studies on
root canal treatment were included and no study comparing the two treatment
concepts pulp capping procedures and root canal treatment of vital teeth could be
identified, which means that there is no evidence supporting the assumption that
pulp capping is more beneficial than root canal treatment in this patient group and
the quality of evidence was regarded as very low according to GRADE (Balshem
et al. 2011). Although the quality was rated as low in all included studies, this
was considered the best available evidence, and the findings constituted the data
regarding pulp capping procedures in young permanent teeth with cariously
exposed pulps in the health economic model.

37
Table 5.
Included studies and information on intervention, material used for the pulp capping and the succes
rate measured in percent.

First author (year) Intervention Material Success rate

Mass (1993) Partial pulpotomy Ca(OH)2 91%
Mejàre (1993) Partial pulpotomy Ca(OH)2 89% (67%*)
Nosrat (1998) Partial pulpotomy Ca(OH)2 100%
Moritz (1998) Direct pulp capping Ca(OH)2 100%
Barrieshi-Nusair Partial pulpotomy MTA 100% (79%**)
(2006)
Farsi (2006) Direct pulp capping MTA 93%
Qudeimat (2007) Partial pulpotomy MTA/Ca(OH)2 93% /91%
Olivi (2007) Direct pulp capping Ca(OH)2 64%
Bogen (2008) Direct pulp capping MTA 97%
Mass (2011) Partial pulpotomy Ca(OH)2 93.5%
*success among the teeth with preoperative symptoms **success if counting teeth that were
unresponsive to vitality but had no other symptoms or signs of infection as failure

The comparison of the cost-effectiveness of pulp capping and root

canal treatment
Pulp capping was proved to be cost-effective compared to root canal treatment.
After initial treatment with pulp capping and follow-up treatments for 9 years,
10.4% fewer molar teeth were extracted, and the cost for the initial treatment was
367 EUR (3498 SEK) less compared to a tooth initially treated by root canal
treatment (Table 6). The sensitivity analysis showed that a constructed worst-case
scenario was the only scenario where root canal treatment could be considered
cost-effective compared to pulp capping, meaning that the annual failure
probability of pulp capping needed to be 0.2 for root canal treatment to be
considered the cost-effective alternative (compared to 0.03 which was the APF
calculated in the normal scenario). In the worst-case scenario, 20% of the teeth
with pulp capping as an initial treatment would receive a root canal treatment or
be extracted every year (Study II, Table 5).

38
Table 6.
The percentage of extracted teeth and the average costs for pulp capping and root canal treatment
and follow-up treatments over 9 years for a simulated patient with pulp exposure due to caries at the
age of 12. Exchange rate €1 = 9.5 SEK (2017-09-25).

InitialTreatment Cost (€) Extractions (%) Incremental Cost-Effectiveness

Ratio (ICER)

Pulp capping Cost-effective alternative

334 4.7
(Dominant)
Non cost-effective alternative
Root canal treatment
701 15.1 (Dominated)

Answers to the questionnaire about awareness of and comfort with

uncertainty

Answers to the questionnaire in January

The answers to the questionnaire at baseline indicated that a minority of the
students stated feeling certain of assessing the risk for exacerbation of apical
periodontitis (Figure 4). At the same time, a majority stated feeling certain or very
certain about their own capacity to handle the case, and a majority stated feeling
comfortable with their ability to handle the situation and do their best for the
patient (Figure 5). There was no significant difference between the distribution
of the answers to the questionnaire before and after the reflection exercise in
January, neither was there any difference between the distribution of the answers
from the students participating in the reflection exercise (Group A) and the
control exercise (Group B).

39
 60

50

40

30

20

10

0
very certain certain neither certain uncertain very uncertain
nor uncertain

Figure 4.
The distribution of the answers from all 51 participants at baseline concerning the question: How
certain do you feel about your assessment of the probability of the patient experiencing an
exacerbation of apical periodontitis within 4 years?

60

50

40

30

20

10

0
very comfortable neither uncomfortable very
comfortable comfortable uncomfortable
nor
uncomfortable

Figure 5.
The distribution of the answers from all 51 participants at baseline concerning the question: How
comfortable are you with your ability to handle the situation and do the best for the patient?

40
Comparing the questionnaire responses within the groups
When the questionnaire was repeated after 5 months, in June, 70% of the students
in Group A (the group that had participated in the reflection exercise in January)
changed their answers to one specific question compared to when the
questionnaire was completed immediately after the reflection exercise in January.
It concerned the question “How certain do you think an experienced colleague
would feel about assessing the probability of exacerbation of apical periodontitis
within 4 years?”, where 58% changed their answer towards more uncertain and
12% towards more certain (p=0.004), see Study III, Figure 2, Panel 1.
For the students in Group B (the group participating in the reflection exercise in
June) 36% of the students changed their answers to one question when the
questionnaire was completed after the exercise compared to the answers before
the reflection exercise. This time it concerned the question: “How certain do you
feel about your own capacity to handle this case?”, where 32% of the students
changed their answers towards more uncertain and 4% towards more certain
(p=0.039), see Study III, Figure 2, Panel 2.

Comparing the questionnaire responses between the groups

There was a difference between Group A and Group B in June when the answers
from the questionnaire completed before the exercises were compared. It
involved the distribution of the answers to the question: “How certain do you feel
about your own capacity to handle this case?” (Table 7).
There was also a difference between Group A and Group B both before and after
participating in the exercises in June with respect to the question, “How certain
do you think an experienced colleague would feel about assessing the probability
of exacerbation of apical periodontitis within 4 years?” (Table 8).

41
Table 7.
Response to the question “How certain do you feel about your own capacity to handle this case” in
June with alternatives and results of the student groups. The p-value is for the comparison of the
distribution of the answers between the groups. Group A participated in the reflection exercise in
January and Group B participated in the reflection exercise in June. When completing the
questionnaire this time Group A had participated in the reflection exercise 5 months earlier and Group
B had not yet participated.

Questionnaire answers Before control and reflection exercises in June

Group A Group B p-value
(n=26) (n=25)

very certain 3 8
certain 15 16
neither nor 5 0
uncertain 3 1
very uncertain 0 0
0.011

Table 8.
Response to the question “How certain do you think an experienced colleague would feel about
assessing the probability of exacerbation of apical periodontitis within 4 years” in June with
alternatives and results of the student groups responses and p-value for the comparison of the
distribution of the answers between the groups. Group A had participated in the reflection exercise 5
months earlier, in January, and for Group B these results show the answers before and after
participating in the reflection exercise.

Questionnaire Before control and reflection After control and reflection

answers exercises in June exercises in June
Group A Group B p- Group A Group B p-
(n=26) (n=25) value (n=26) (n=25) value

very certain 3 5 2 2
certain 4 11 8 14
neither nor 15 6 11 9
uncertain 4 3 5 0
very uncertain 0 0 0 0
0.038 0.045

42
Dental students’ reflections on clinical experience in relation to
uncertainty

All 52 included students completed the reflection exercise on one of two

occasions, in January or in June. Three themes were identified in the students’
texts about experience. The first theme the meaning of clinical experience, was
divided into five subgroups. The second theme assumed differences regarding
assessment, was divided into three subgroups and the third theme relating to the
same risk factors was not subdivided, see Study IV for more elaborate
descriptions and illustrating citations.

Theme 1. The meaning of clinical experience

1.1 Encountering several similar cases leads to knowledge about the probable
development of apical periodontitis
Several participants described how an expert would have the experience of
encountering and treating several similar cases and that it would lead to
knowledge about risk and recognizing specific types of apical destructions as
well as their probable course of development.

1.2 With experience comes knowledge of risk factors

Participants wrote that experts have more knowledge. Some participants
mentioned that experts use their experience to see the whole picture and are
better able to relate the risk for exacerbation of apical periodontitis to the
patient’s general health.

1.3 Experts have the answers

Several participants also described how experts have had the opportunity to
follow root-filled teeth and how they have been able to see the outcome of their
treatment decisions.

1.4 Experts are more prone to wait with intervention

Some participants wrote that experts feel more confident in deciding when to
retreat and when to wait and see and some thought that an expert would be more
prone to wait and see.

43
1.5 The ability to perform treatment affects the decision to intervene
In contrast to the participants who thought that an expert would be more likely
to wait with treatment, some participants wrote that the experts’ ability to
perform a better treatment would affect the treatment choice in favor of
retreatment of root-filled teeth.

Theme 2. Assumed differences regarding assessment

2.1 A lack of primary experience makes it more difficult to assess the risk
Some of the participants expressed that more experience would make risk
assessment easier, and they themselves only had theoretical experience but
lacked clinical experience of assessing the risk for exacerbation.

2.2 Experienced and inexperienced dentists make different assessments

Several participants wrote that an expert and a novice would make different
assessments. One student pointed out that, although the risk factors were the
same, the assessment could differ because of experience.

2.3 Inexperienced dentists may over diagnose and perform too many
examinations
Some participants wrote that novices would perhaps over diagnose and perform
too many examinations. One participant wrote that the fear of exacerbation
could lead to over diagnosis.

Theme 3. Relating to the same risk factors

Several participants pointed out that experts and novices must relate to the same
risk factors and the same facts. At the same time, a number of participants wrote
that experience helps when assessing risk and that the expert’s assessment could
differ from a novices’ due to experience.

44
DISCUSSION

This thesis adds information about the cost-effectiveness of pulp exposure

treatment in young permanent teeth, which is intended to reduce the uncertainty
for clinicians and policy makers. It also adds information about reflection to help
dental students understand and acknowledge uncertainty and about students’
beliefs on the relation between clinical experience and certainty.

Main findings
The results from the model in Study II, based on data from the systematic review
in Study I indicate that pulp capping was cost-effective compared to root canal
treatment in children and adolescents with pulp exposure due to caries. They
moreover show that the annual failure rate for pulp capping need to be at least six
times higher than suggested in the systematic review to ensure root canal
treatment is cost-effective.
After constructing and testing the reflection exercise among a group of students
the results suggest that most students did not feel certain about assessing the risk.
Nonetheless, they felt certain of their capacity to handle the case and comfortable
with their ability to handle the situation and do their best for the patient, even
though there was considerable uncertainty involved in the case. The reflection
exercise had a delayed effect, and 5 months after the exercise, there was a
significant change in how the students answered the question about how certain
they thought an experienced colleague would feel when assessing the risk.
Three themes and eight subgroups were identified in the qualitative analysis of
the students’ written reflections: Theme 1 “The meaning of clinical experience”,
Theme 2 “Assumed differences regarding assessment” and Theme 3 “Relating to
the same risk factors”.

45
Quantitative or qualitative methods
Although there are differences between quantitative and qualitative methods, they
both need to meet fundamental scientific criteria and the choice between a
quantitative and a qualitative method should be driven by the research questions
(Malterud & Midenstrand 2009). Quantitative approaches were chosen to answer
the questions in Study I and II about whether pulp capping is more beneficial than
a root canal treatment in achieving a symptom free tooth with normal periapical
conditions, and determine which treatment is cost-effective in a child with a
cariously exposed pulp in a permanent tooth. A quantitative approach was also
chosen to answer the questions in Study III about whether final year-dental
students acknowledged their uncertainty when assessing the risk of exacerbation
of apical periodontitis in root-filled teeth and whether a reflection exercise could
improve the students’ ability to acknowledge the uncertainty and improve their
feelings of comfort with uncertainty.
Answering the research question about how the students reflected on clinical
experience in relation to uncertainty when assessing the risk for exacerbation of
apical periodontitis would not be possible with a quantitative methodology.
Therefore, in Study IV, a qualitative method, STC was used to analyze the written
reflections from Study III.
Instead of analyzing the data in Study III and Study IV separately, a mixed
methods design could have been used to analyze the combined data from Study
III and Study IV. For example, the reflections from the students who stated
feeling certain about their assessment in the questionnaire in Study III, could have
been studied separately. This could possibly have provided more insight into how
these students reflected on the relationship between experience and certainty.
Another approach could have been to interview some students with surprising
answers to the questionnaire in order to gain deeper insights.

Study I - Systematic review

The systematic review identified ten studies on pulp capping. Prior to this study,
there were no systematized data in which success rates specifically for young
permanent teeth treated with pulp capping or pulpectomy had been extracted from
the study population. Unfortunately, the quality was rated as low in all included
studies, mainly because they all a lacked relevant control group when the aim was
to compare pulp capping and root canal treatment.

46
Since the systematic review was published in 2016 additional publications on
vital pulp treatment in teeth with pulp exposure due to caries have been published.
New searches on PubMed using the same search strategies as in Study I (Table
1), including studies published between 2013 and 2021, revealed no study
answering the research question comparing pulp capping procedures with root
canal treatment. Instead, recent research seems to have shifted towards
advocating full pulpotomy with MTA instead of partial pulpotomy (Wang et al.
2022) which means that an update of the systematic review in Study I would no
longer be relevant if it did not also include full pulpotomy.
New searches using the search strategy from Study I (Table 1) identified one
study comparing full pulpotomy with root canal treatment in permanent molar
teeth with pulp exposure due to caries, in which the success particularly for
patients aged ≤20 could be extracted. The success at follow-up after 5 years for
the patients aged ≤20 with irreversible pulpitis was 75% (24/32) for full
pulpotomy with calcium-enriched mixture cement and 68% (17/25) for
pulpectomy (Asgary et al. 2015). A recent systematic review trying to answer the
question: “is pulpotomy (partial/full) as effective as a pulpectomy, in terms of a
combination of patient and clinical reported outcomes, with ‘tooth survival’ as
the most critical outcome?” identified another study comparing full pulpotomy to
pulpectomy (Jakovljevic et al. 2022). The study reported treatment success in
81.5% (22/27) of the teeth treated with full pulpotomy and 77.8% (21/27) of the
teeth treated with pulpectomy (Galani et al. 2017). The patients were between 15
and 50 years of age. The risk of bias in the study was rated as low. Unlike in
Study I, studies without direct comparisons were excluded from the review
(Jakovljevic et al. 2022). If this exclusion criterion had been used in Study I, no
study would have been included in the review at the time.
The updated literature searches also revealed a prospective study on the success
rate of root canal treatment in young permanent teeth. Undergraduate students
treated molar teeth with extensive caries in patients of age 9–17 years. At the time
of treatment 29% had no periapical lesion. Unfortunately, no data on the success
for the treatment of these teeth were reported separately. After two years, 93%
(64/69) of all root-filled teeth were symptom free and apical healing could be
seen in 91% (63/69) (Cunha et al. 2020). Studies on root canal treatment in young
permanent teeth are still scarce, and there is still uncertainty regarding the long-
term outcome for permanent teeth with pulp exposure due to caries.

47
Study II - Health economic model
The systematic review in Study I formed the basis of Study II. The results from
the health economic model can provide guidance and reduce uncertainty when
deciding on which treatment to choose for young patients with pulp exposure due
to caries. However, the results from a model analysis are completely dependent
on available data and the low-quality data on pulp capping in young permanent
teeth included in the systematic review, renders the results less certain than
models based on more robust data. Typical shortcomings of the clinical trials that
form the basis of a model analysis are short follow-up, lack of control groups,
small patient populations and use of surrogate measures. All of these can create
uncertain results and negatively affect the internal validity of the model (Gruneau
et al. 2022). Sensitivity analyses provide an opportunity to test what happens to
the results when some of the uncertain parameters are changed (Schwendicke &
Herbst 2022). Sensitivity analyses were performed for different failure rates for
pulp capping since the evidence for the success of pulp capping was rated as low.
However, no probabilistic sensitivity analysis was conducted since the model was
based on several studies based on uncertain data and a probabilistic analysis
would not strengthen the results.
If the wrong treatment decision is made based on an uncertain cost-effectiveness
analysis, patients’ risk being exposed to costs in the form of lost health benefits.
In this model, a patient could for example experience pain due to pulpitis. After
conducting a probabilistic sensitivity analysis, it is possible to calculate if more
data on the success rates of the treatment methods would reduce the uncertainty
by analyzing the Value of Information (VOI). In these calculations the expected
cost of making the wrong decision is related to the cost of acquiring more
knowledge through research. The Expected Value of Perfect Information (EVPI)
can be estimated assuming that perfect information would eliminate the
possibility of making the wrong decision (Gruneau et al. 2022). The value of
further research will thus depend on how cost-effective the treatment is expected
to be and the size of the population that would benefit from the additional research
(Briggs et al. 2006).
The only initial treatments possible in the model were pulp capping or root canal
treatment. Extraction was possible at follow-up after a year and the ultimate
outcome in the model was tooth survival measured in years. This was one step in
the direction of using a patient centered outcome. For some patients, saving teeth
from extraction whenever possible is regarded as important (Gatten et al. 2011).

48
A Swedish study on oral health related quality of life reported high patient
satisfaction 1–3 years after starting root canal treatment (Wigsten et al. 2021) but
there is a lack of corresponding data on patient reported outcome in vital pulp
treatment (Cushley et al. 2022).
Initially, the intention was to base the cost for pulp capping on the real time spent
by general dentists when they performed a pulp capping. A short survey was
handed out to general dentists working in different dental clinics in Malmö and
Uppsala, but unfortunately, few time measurements were performed, and the data
was not considered robust enough. Therefore, the predefined fees from the Dental
and Pharmaceutical Benefits Agency were used instead, where the time for
different procedures are included in the price. Since the Dental and
Pharmaceutical Benefits Agency has no predefined fee for pulp capping, the
predefined fee for a composite filling was used. In the future, a predefined fee for
pulp capping would not only facilitate cost estimation but also enable prospective
research on teeth receiving a pulp capping, since it is possible to follow all
treatments reported to the Swedish Social Insurance Agency. Since the model
was made from the care provider’s perspective, no indirect costs were included
in the analysis.
The data underlying the model was data that was available at the time of
conducting the study. As new research findings emerge, the outcome may change.
For the calculation of the annual failure rates of root canal treatment, the results
from a large amount of material from the Swedish Social Insurance Agency were
used, where data from the youngest age group of 20–24 were used to calculate
how many root-filled teeth were extracted. In the prospective study on the success
rate of root canal treatment in young permanent teeth identified when the searches
on PubMed were repeated using the same search strategies as in Study I, 8%
(6/75) of the teeth were extracted within the first two years after completing a
root filling (Cunha et al. 2020). According to the formula for annual failure
probability (AFP) used in the model, this corresponds to an AFP of 0.04 which is
higher than 0.018 AFP that was used in the model based on the data from 1121
patients registered in the Swedish Social Insurance Agency. Even if these
numbers where from younger patients, the patients were treated in Brazil and
therefore it is not certain that they represent the Swedish young population better
than the numbers on the Swedish individuals aged 20–24. Moreover, treatment
choices can be affected by dental insurance systems and the cost for extraction
and root canal treatment can affect the proportion of extracted teeth.

49
It is difficult to transfer results from health economic evaluations to other settings.
The results from the health economic evaluation (Study III) are valid in a Swedish
setting where dental care at the time of the study was tax-funded for children and
adolescents up to 20 years old. At present in Sweden, dental care is tax-funded
up to the age of 23. It is not certain that the results would be valid in other settings
where other treatments could be available for young patients. For example, crown
restorations were not included in the evaluation since they were very uncommon
in this patient group at the time (Norderyd et al. 2015).

Study III - Repeated questionnaire about awareness of and comfort

with uncertainty
The answers from the repeated questionnaires indicated that the students
interpreted the source of uncertainty both as a lack of information and lack of
personal knowledge. The answers also indicated that a majority of the students
believed that an experienced colleague would feel certain about assessing the risk.
To study if the students’ feelings of uncertainty and comfort with uncertainty
changed after the reflection exercise, half of the students were randomized to
participate in a control exercise, and the questionnaire was repeated after the
exercises. The questionnaire was constructed for this study since no suitable
validated instrument could be identified. The questionnaire was based on Ilgen et
al. (2019) and their proposed three different sources of uncertainty and a 5-point
Likert-type scale were used. It was tested in a pilot and the questions were
adjusted after feedback from the participants.
When comparing the answers to the questionnaire completed by the students
participating in the reflection exercise in January, there was no significant
difference in the distribution of the answers before and after the reflection
exercise. However, when asked to complete the questionnaire again, five months
later, there was a change in the distribution of the answers to one specific question
regarding how an experienced colleague would reason. For the other group
participating in the reflection exercise in June, there was a change to the
distribution of the answers to the question of how certain they felt about their
capacity to handle the case, before and after the reflection exercise.
If the reflection exercise were to be introduced into the curriculum as a regular
feature, the students should receive feedback, which was not the case in Study
III. Receiving feedback after reflection is recommended (Aronson 2011), but
since a crossover design was applied, the students receiving feedback could have

50
influenced the students in the other group who had not yet participated in the
reflection exercise. The prompts used for reflection by Ryan & Ryan (2012) are
part of a model for teaching and assessing reflective learning, where the prompts
for reflection are one part of the model. It is suggested that a shared language
should be developed for both faculty staff and students describing the levels of
reflection in assessment descriptions and criteria sheets.

Study IV - Reflections on clinical experience

The overall impression after reading all written reflections was that the students
engaged most in their critical reflection to the prompts about experience which is
interesting since the students also changed the answers to the question about an
experienced colleague in the questionnaire. The level of reflection was not
evaluated in Study III but when all reflections were read to create preliminary
themes, the reflections to prompts 1–5 were considered less interesting and
mostly concerned information perceived as missing. Clinical experience as a
perceived key factor was not obvious before reading all the reflections but the
results from the questionnaires also gave some guidance towards experience as a
phenomenon of interest. To help students with critical reflection different
prompts and frameworks have been developed by, for example Gibbs (1988) and
Rolfe et al. (2001). Both are used in dental education (Crowe & Woolley 2022)
and they are both similar to the one created by Bain et al. (2002), altered by Ryan
& Ryan (2012), used in Study IV. The prompts begin by asking the student to
describe the event and ultimately lead to questions on how the student could
perform next time.
One explanation to the student’s belief that experience leads to certainty could be
the “culture of certainty” in dental education described by von Bergmann and
Shuler (2019). If dental teachers fail to show students that there may not always
be one single correct answer and that there are cases where the answer or
diagnosis is uncertain, students may perceive that experts have all the answers
and that it is always possible to be completely certain.

51
Studies indicate that medical students reproduce their supervisors’ attitudes
towards uncertainty (Bochatay & Bajwa 2020). Fox (1957) described how
medical students were encouraged to accept uncertainty by watching their
instructors dealing with uncertainty:

“In short, observing his teachers in various classroom and clinical situations makes
a student more aware of the fact that they are subject to the same kinds of
uncertainty that he himself is experiencing. Furthermore, the student notes that
when his instructors experience these uncertainties, they usually deal with them in
forthright manner, acknowledging them with the consistency of what a student has
termed a “philosophy of doubting”. Thus, a student’s relationship to the faculty,
like his advances in knowledge and skill, encourages him to accept some of his
uncertainty as “inevitable” and thoroughly “legitimate” and to handle that
uncertainty by openly conceding that he is unsure.”

Even if the students’ reflections revealed that many students believed that they
would feel more certain if they had more clinical experience, it is not certain that
more experience would improve their risk assessment skills. Among
undergraduate students from the Netherlands, self-efficacy and self-perceived
competence was rated as higher among students who had performed a greater
number of root canal treatments under the supervision of an endodontist.
However, the quality of the root canal treatment was not statistically significant
related to their self-efficacy and self-perceived competence (Baaij & Özok 2018).
The results from the analysis of the reflections were described as themes and
subgroups according to the steps of the STC. The method has its roots in
phenomenology where the results describe the manifest content of the data, as
opposed to other qualitative methods where a latent, underlying meaning is
interpreted from the text and described (Graneheim et al. 2017). A less abstract
analysis of the text, as in STC, seemed suitable to analyze the reflections since
the data constituted of short written material, and latent meaning could be difficult
to draw from such limited data.
Another potential shortcoming in analyzing responses to written questions, in
addition to limited data, is the risk of leading questions. The students were asked
to explain if the experts’ reasoning was different from theirs. They could have
interpreted that there was indeed a difference, and they should be able to explain
it.

52
Clinical implications
The results from Study I and II can provide guidance towards a cost-effective
treatment for teeth with pulps exposed by caries. However, longer prospective
studies about pulp capping and pulpectomy in young permanent teeth would add
more certainty to treatment recommendations.
The reflection exercise in Study III combined with instructions before reflection
and feedback after reflection, could be used in the endodontic education.
Moreover, it could also be modified to suit other areas in dental education to help
students acknowledge uncertainty and make better treatment decisions in the face
of uncertainty.
The analysis of the reflections revealed that the students believed that with
clinical experience comes certainty and that clinical experience would help in
making risk assessment even when there is little scientific evidence. For clinical
instructors and experts involved in teaching dental students, the findings from
Study VI gives some insight into how students think about uncertainty related to
experience and together with students they can find ways to explore strategies for
action under uncertainty.

Statistical analysis
The data from the questionnaire in Study III, where the answers were on a 5-point
Likert-type scale, were analyzed with non-parametric tests (Mann-Whitney U-
tests and Wilcoxon signed rank test). Likert scales are ordinal but are sometimes
treated as a nominal scale, and there is a debate about using parametric versus
non-parametric methods for the analysis (Mircioiu & Atkinson 2017).
Transforming scores from a Likert scale into nominal scores would imply that the
difference between “very uncertain” and “uncertain” is equal to the difference
between “neither certain nor uncertain” and “certain”, and since that cannot be
guaranteed, non-parametric tests were chosen for the analysis (Streiner &
Norman 2008).

Ethical considerations
The Regional Ethics Review board in Lund ruled that ethical reviews were not
necessary for the health economic analysis (Dnr 2016/810) or educational studies
(Dnr 2019/02441) since no personal information was collected.

53
Study I–II
Using a model to compare the effectiveness of interventions is a way of using
existing data from clinical studies or register data without conducting a new
clinical trial. Even if a randomized controlled trial would contribute with a
significant amount of information, conducting a randomized controlled trial
where patients were randomized to either a pulp capping procedure or a root canal
treatment would be questionable from an ethical standpoint since one of the
treatments is very invasive compared to the alternative. This is especially true
with respect to children and adolescents, because research involving children is
always sensitive and should be avoided when possible. Therefore, a model
analysis is a more ethical alternative.

Study III–VI
The participation in the educational exercises was voluntary. One student
participated in the sessions but did not consent to participate in the study and their
results were not included in the analysis. The results from the participating
students were anonymized and presented without revealing individual details that
could enable identification of the study participant. Citations were presented as
anonymous citations translated into English.

54
CONCLUSIONS

 There is a lack of prospective studies concerning pulpectomy in young

permanent teeth with pulp exposure due to caries.

 The existing studies on the outcome of pulp capping procedures in

children and adolescents with pulp exposure due to caries are of low
quality when the aim is to compare with the outcome of pulpectomy.

 Pulp capping procedures are cost-effective compared to root canal

treatment for children and adolescents with pulp exposure due to caries.

 Most final-year dental students participating in a reflection exercise did

not feel certain of assessing the risk for exacerbation of apical
periodontitis in root-filled teeth but still felt certain of their capacity to
handle the situation and comfortable with their ability to do their best
for the patient.

 A reflection exercise affected the students’ statements on how certain

they felt of their own capacity and how certain they thought an expert
would feel about assessing the risk for exacerbation of apical
periodontitis associated with root-filled teeth.

 The participating students’ reflections indicated that they believed that

with clinical experience comes certainty and that even when the scientific
evidence is lacking, clinical experience helps when making risk
assessment.

55
  Experts and clinical instructors should be transparent with their own
uncertainty. Strategies for action under uncertainty could be explored
together with students.

Suggestions for future research

If the Markov model was to be extended in the future, more treatment alternatives
could be incorporated in the model, for example, extraction with or without tooth
replacement. The model could also include orthodontic treatment after extraction,
and it could differentiate between pulp capping and full pulpotomy. Calculations
could also compare the cost-effectiveness of different materials for pulp capping
and the analysis could be conducted from other viewpoints, for example from the
patient’s viewpoint including indirect cost in the analysis.
If future prospective studies on pulp capping procedures and root canal treatment
included patient reported outcome measures, this dimension could also be added
to the model, comparing the effects on the quality of life after different treatment
concepts.
Various ways of formal training for uncertainty in the dental curriculum could
also be investigated. Future educational studies should include clinical instructors
involved in dental education and examine how they perceive and manage
uncertainty, since this will probably be reflected in their teaching and could affect
how their students learn to manage uncertainty. Further, the questionnaire and the
reflection exercise could be tested in other settings with other dental students to
find if there is a difference between students attending different dental education
programs.
It would also be important to study whether comfort with uncertainty affects risk
assessment and treatment decisions made in the dental clinic and whether a low
comfort with uncertainty among dentists leads to adding more diagnostic tests
and involves risk of overtreatment.
The questionnaire and the reflection exercise could also be used in a group of
dentists. Considering the results indicating that dental students believe that
clinical experience creates certainty, it would be interesting to compare dentists
with little clinical experience to a group of dentists with more clinical experience.

56
AUTHOR CONTRIBUTIONS

The author of this thesis participated substantially in the studies by doing the
following:

Study I
designing the study and the research protocol, analyzing and interpreting the data
and the results, writing the first draft of the manuscript and submitting the
manuscript.

Study II
designing the study, creating the model in Microsoft Excel, collecting the
background data for the model, analyzing and interpreting the data and the results,
writing the first draft of the manuscript and submitting the manuscript.

Study III
designing the reflection exercise, the control exercise, and the questionnaire,
carrying out the exercises in Canvas, analyzing the data, interpreting the results,
writing the first draft of the manuscript and submitting the manuscript.

Study IV
designing the reflection exercise, collecting the data, analyzing the data,
interpreting the results and writing the first draft of the manuscript.

57
ACKNOWLEDGEMENTS

I am very grateful to everyone who has inspired and supported me during the
work with this thesis.

I would especially like to express my gratitude to:

Helena Fransson, my main supervisor. Thank you for your continuous support,
for never giving up on our projects and for being such a good friend.
Maria Pigg, my supervisor. Thank you for all your advice and support. I look
forward to collaborating with you and Helena in the future and to attending
interesting conferences together.
Thomas Davidson, my supervisor. Thank you for helping me understand health
economics and for your collaboration when working on the health economic
model.
Kerstin Petersson. Thank you for giving me the chance to become an
endodontist which opened the door to all the fantastic research possibilities in the
field of endodontics.
Gunnel Svensäter and Madeleine Rohlin for including me in the Foresight
research program and opening my eyes for research in the field of dental
education.
Christina Lindh who supported me at the beginning of the research project.
Niklas Vareman for collaboration with Paper III and IV.
Emma Wigsten for all the honest advice, discussions and for regularly checking
in on me to make sure I wasn't too lonely when I was working remotely.

58
The colleagues at the National Dental Research School for many interesting
discussions.
The researchers in EndoReCo.
Christina Stenervik for always being very helpful with practical issues during
the PhD studies.
Håvard Heimdal and Oliver Josefsson Co-authors in Paper I.
The former dental students at Malmö University who participated in the studies.
Caroline Riben Grundström for valuable advice about research and unrelated
topics.
Maria Granevik for many valuable discussions about endodontology and
research.
My former colleagues at the endodontic department at Kaniken in Uppsala.
My parents Ingalill and Jacques Audibert, and my parents-in-law Kerstin and
Sigvard Brodén for babysitting when I was away on courses and at conferences.
My Becker for giving me a place to stay when I needed to stay in Malmö
overnight.
My husband Mats and my children Märta and Nils for all your love and support.

The research was funded by:

Sydsvenska Tandläkare Sällskapet, OFRS (Odontologisk Forskning i Region
Skåne), Folktandvården Uppsala, Foresight Malmö Universitet and ADSS
(American Dental Society of Sweden).

59
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APPENDIX

69
 13652591, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13679 by Cochrane Sweden, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 30 September 2021
| Accepted: 28 December 2021

DOI: 10.1111/iej.13679

REVIEW

How do we and how should we deal with

uncertainty in endodontics?

Maria Pigg1 | Joséphine Brodén2 | Helena Fransson1 | EndoReCo |

the Foresight Research Consortium | Niklas Vareman3

1
Department of Endodontics, Faculty of Abstract
Odontology, Malmö University, Malmö,
In many clinical cases a dentist may feel certain when for example diagnosing, de-
Sweden
2
Department of Oral Biology, Faculty of
ciding on treatment, or assessing the prognosis—­in other cases many dentists may
Odontology, Malmö University, Malmö, feel a degree of doubt or uncertainty. This paper aims to explore the philosophical
Sweden concept of uncertainty and its different dimensions, using the condition “persistent
3
Department of Medical Ethics, Lund
apical periodontitis associated with a previously root filled tooth” as an example.
University, Lund, Sweden
Acknowledging that uncertainty exists in any clinical situation can be perceived as
Correspondence uncomfortable, as some might regard it as a weakness. Whilst some types of uncer-
Maria Pigg, Department of
tainty met in dental practice can be addressed and reduced, there are other types
Endodontics, Faculty of Odontology,
Malmö University, SE-­205 06 Malmö, which are inevitable and must be accepted. To make sound decisions, it is pertinent
Sweden. that the dentist reflects on and values the consequences of uncertainty. In this paper,
Email: maria.pigg@mau.se
a conceptual model is presented by which the dentist can identify the type of uncer-
Funding information tainty in a clinical case, making it possible to decide on a strategy on how to manage
The Foresight Research Consortium is the uncertainty and its possible consequences, with the aim to support the dentist's
funded by grants received from Malmö
University. 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 under-
graduate education. Some suggestions on how teachers could target this are given in
the paper.

KEYWORDS
[clinical] decision making, endodontics, patient preference, periapical periodontitis, philosophy,
uncertainty

I N T RO D UCTI O N probably fairly certain that there is an infectious condition

that requires treatment. But how certain is the clinician
Assessment of a previously root filled tooth with apical when assessing and proposing actions regarding a previ-
periodontitis can be straightforward; if the patient is expe- ously root filled tooth with persistent apical rarefaction
riencing symptoms both the patient and the clinician are when the patient has no symptoms? The patient is probably

The researchers within the Endodontic Research Collaboration in Scandinavia contributed to this study. EndoReCo collaborators: L. Bjørndal, V.S.
Dawson, H. Fransson, F. Frisk, P. Jonasson, T. Kvist, M. Markvart, M. Pigg.
The Foresight Research Consortium: Listing of partners on: https://mau.se/en/resea​rch/resea​rch-­progr​ammes/​fores​ight/.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd on behalf of British Endodontic Society.

282 | wileyonlinelibrary.com/journal/iej
 Int Endod J. 2022;55:282–289.

PIGG et al.
unaware of the condition until the clinician informs about
the findings from the radiograph and may question whether
an additional intervention is indicated. Even though the
European Society of Endodontology (ESE, 2006) states that
follow-­ups should be performed, dentists admit that these
are often neglected (Malmberg et al., 2020; Markvart et al.,
2018). Is this due to the high probability of finding periapi-
cal healthy conditions? Or does it perhaps reflect uncer-
tainty as to whether the possible finding of persistent apical
periodontitis would lead to a further intervention?
The classical work by Strindberg (1956) has been the
foundation for academia when students learn how to as-
sess and act on persistent apical periodontitis associated
with a root filled tooth and forms the basis for the recom-
mendations from the European Society of Endodontology
(ESE, 2006). In summary, the paper proposed that apical
periodontitis that persists after 4 years should be seen as
an unfavourable outcome and require further treatment.
However, from various studies it is obvious that clini-
cians do not follow these recommendations strictly, or
perhaps not at all; for example, a systematic review re-
ported that 41% of root filled teeth had apical periodonti-
tis (Jakovljevic et al., 2020). Yet, few retreatments of root
fillings are performed by general dentists (Fransson et al.,
2016; Petersson et al., 2016; Wigsten et al., 2019).
In other words, there seems to be a dissonance between
practice and beliefs regarding apical periodontitis associ-
ated with a previously root filled tooth. In this review, it can
be argued that this dissonance could be at least partly ex-
plained by various types of uncertainty. Hence, this paper
will present a philosophical discussion on uncertainty and
provide examples related to persistent apical periodonti-
tis associated with root filled teeth. This clinical scenario
should be seen as just one example within endodontics of a
situation where uncertainty may be present, but a decision
on patient management must be made, nevertheless. Other
examples may be assessment of the severity of pulp inflam-
mation (i.e., is it possible or not possible to reverse pulp
inflammation by using conservative pulp treatment) or as-
sessment of prognosis for a tooth displaying a visible crack
or root resorption, etc. Strategies to manage uncertainty in
endodontics and how dealing with uncertainty could have
implications for education will also be proposed.
R E VI E W
What is uncertainty?
Uncertainty is present when we do not know. This can
be because we simply have less information than we need
or it can be because we are fully informed about a pro-
cess in the world that is inherently uncertain. This reveals
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283
two different sources of uncertainty: the epistemic state
of the individual and the state of the world. The differ-
ence is conveyed through the use of language: that I am
uncertain whether the radiograph shows a tooth with api-
cal periodontitis is an example of the first kind of uncer-
tainty versus if I claim that it is uncertain whether what
is seen on the radiograph represents apical periodon-
titis (disease) or not suggests the second kind of uncer-
tainty. The former has been variably termed incertitude or
internal/epistemic uncertainty and the latter natural vari-
ability or external/aleatory uncertainty (Juanchich et al.,
2017). Whether these are synonyms or if they are distinct
concepts is debatable (Fox & Ülkümen, 2011). What they
all want to capture, in their possibly somewhat differ-
ent ways, is that some dimensions of uncertainty exist as
features of the external world that we must accept (the
aleatory/external/variability type), but also that some
dimensions of uncertainty are due to our limited knowl-
edge (the epistemic/internal/incertitude type) that can
be reduced by improving our epistemic situation; that is
our understanding. Both can ideally be expressed quanti-
tatively through probabilities, or, when epistemic uncer-
tainty is significant, with probability intervals (Kyburg,
1974) or qualitative expressions to that effect (Mach et al.,
2017; Moss & Schneider, 2000). The types of uncertainty
discussed in this paper are explained in Table 1, and gen-
eral examples are provided.
Uncertainty matters perhaps most when we are about
to make decisions. In the choice between action alterna-
tives, we need to know in what state the world might be
and what the consequences will be if an act is performed
given a certain state of the world. Uncertainty regarding
what state will exist can be external, if random processes
are at work, but of course also internal. What the conse-
quences will be can also be uncertain due to features of
the world and in addition, by what we presently know, or
can imagine, about what may follow on a certain action.
There are many different definitions of uncertainty,
and several different suggestions of a taxonomy of uncer-
tainty. Many are discussed in a review by Han et al. (2011),
in which also a taxonomy for uncertainty in health care
is presented. The basic concept of Han et al. (2011), and
one that is borrowed from Smithson (1989), is that uncer-
tainty has a source and an issue, that is, what gives rise
to it and to what it applies, respectively. The sources are
“probability”: events that are indeterminate, “ambiguity”:
information of the event is unreliable or inadequate, and
“complexity”: difficulties in structuring the decision prob-
lem for example due to a multitude of possible outcomes
of a treatment. The issues are “scientific”: diagnosis, prog-
nosis, causal explanations, treatment recommendations;
“practical”: structures of care, processes of care; and “per-
sonal”: psycho-­social, existential (Han et al., 2011). To put
 |

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284    UNCERTAINTY IN ENDODONTICS

TABLE 1 Terms related to various types of uncertainty discussed in this paper, with explanations and examples

Term Explanation Example

Internal uncertainty (incertitude) Uncertainty pertaining to the knowledge of I am uncertain if/how/when/what/which etc
the individual
External uncertainty Uncertainty pertaining to the state of the It is uncertain if/how/when/what/which etc
external world
Epistemic uncertainty Systematic uncertainty X is unknown in practice (but could on
principle be known)
Aleatory uncertainty (natural variability) Statistical or random uncertainty X is unknown because it varies in a random
(or extremely complex) manner
Ambiguity Inexact, undefined, or possible to interpret X depends on what is meant by Y
in more than one way

F I G U R E 1 Various types of uncertainty exemplified in the case of a root filled tooth with persistent apical periodontitis. Identifying the
source and the issue of uncertainty in a specific case will clarify the nature of uncertainty and be helpful to guide how it might be managed.
(Figure based on Han et al., 2011)

it in general terms, the issues to which uncertainty apply
comprise anything that has a bearing on decision making:
what alternative actions there are, what state the world
might be in at the time action is taken, what the conse-
quences of the acts, given a certain state of the world,
might be, and how to value these consequences. The locus
can be the physician or the patient, or both (Han et al.,
2011), that is, the physician can entertain uncertainty and
so can the patient.
As is clear from the choice of issues, Han et al. (2011)
aimed at identifying types of uncertainty in the full context
of treatment, from scientific statements about diagnosis
and effective treatment alternatives, through the ability of
the system to provide the treatment, to the patients’ view on
how an illness and possible treatment will affect their life.
In the following, the basic structure from Han et al.
(2011) will be used but the focus will be more narrowly
on the scientific issues, from the practitioner's perspective.
Figure 1 exemplifies the conceptual model by identifying
uncertainty regarding the diagnosis of root filled teeth with
persistent apical periodontitis. The issues in Figure 1 are
not about the areas of science, organization, person, as they
are in Han et al. (2011). Instead, they are all in the area of
science, where “scientific” is about scientific knowledge
about the phenomenon, “practical” refers to uncertainty re-
garding methods for prediction, assessing risk, or for iden-
tifying states, and “personal” is the epistemic uncertainty,
lack of training, etc. of the individual practitioner.
The sources are first “probability”, or perhaps knowl-
edge, which indicates that there is a lack of information,
or knowledge, on which to base a reliable judgement.
Second, there is “complexity”. The causes of a negative
event can be many and intertwined, and the scientific un-
derstanding is inadequate, but complexity can also lead

PIGG et al.
to unreliable risk assessment models and to a practitioner
being insecure about what risk factors to focus on in the
discussion with the individual patient. Lastly, “ambiguity”
encompasses a source of uncertainty that is not clearly
present in Han et al. (2011), that is, linguistic uncertainty.
With poorly defined scientific concepts follows a lack of
precision in the diagnosis and the possibility of disagree-
ment between practitioners based not on facts but on a dif-
ferent understanding of vague or ambiguous terms. The
source of ambiguity can also be conflicting information on
which it is difficult for the practitioner to base a decision.
What are the implications of uncertainty
for the practitioner?
Uncertainty is well known in medical practice, and the
same is true for dentistry. As discussed above and pro-
posed in Figure 1, the clinical situation involves uncertainty
in many ways. Why does this matter, and how does it af-
fect the dentist? No publications address this issue, but in
emergency medicine, it has been suggested that intoler-
ance of uncertainty and ambiguity, particularly regarding
outcome of treatment, is associated with practitioner anxi-
ety and burnout, and reluctance to admit uncertainty and
mistakes to patients and other practitioners, which suggests
suboptimal communication (Kuhn et al., 2009). In general
medical practice, low tolerance for ambiguity has also been
associated with a biomedical rather than a biopsychosocial
worldview of the practitioner, and failure to comply with
evidence-­based guidelines (Geller, 2013). In contrast, high
tolerance for ambiguity in dual-­degree students (Doctor of
Medicine and Master of Business Administration) was as-
sociated with superior leadership abilities (Sherrill, 2001).
It thus appears likely to be beneficial for the dentist—­and
endodontist—­both as practitioner and as practice leader to
recognize, understand, and tolerate uncertainty.
Possible strategies to manage uncertainty
when encountering a root filled tooth with
persistent apical periodontitis
Acknowledging uncertainty and identifying
what the issue is
To be able to handle clinical uncertainty in a conscious
way, dentists first need to acknowledge that uncertainty
exists. This may be more challenging than it sounds. The
present paradigm by which we understand the world leans
heavily towards positivism (in which reality is defined in
terms of scientifically proven facts and logical principles)
and away from humanism (in which human experience
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   285
and rational thinking are necessary means to understand
reality). This paradigm tends to encourage operational-
ized, simplified management strategies and discourage
reflection, pluralism, and acceptance of variations. As a
result, a culture of certainty prevails within many profes-
sions, dentistry included (von Bergmann & Shuler, 2019).
Yet, a review examining a variety of healthcare settings
concluded that professional uncertainty in scientific,
practical, and personal domains as described by Han et al.
(2011) exists throughout healthcare disciplines (Pomare
et al., 2019). The emergence of systematic literature re-
views in recent years may actually have alerted dentists
and other healthcare professionals to the presence of un-
certainty by revealing the lack of evidence for the valid-
ity or efficacy of various procedures. Still, acknowledging
feelings of uncertainty may feel uncomfortable and the
dentist may feel that it even threatens their professional
credibility. To increase comfort with feelings of uncer-
tainty, it may be helpful to first identify the issue to which
the uncertainty applies, for example, if the uncertainty ex-
ists in the domain of diagnosis, prognosis, causal explana-
tions, or appropriate treatment choice (Han et al., 2011).
Figure 2 shows a case of (possible) apical periodontitis
associated with a root filled tooth and exemplifies how
uncertainty in a specific clinical case may well exist in
several or all of those domains.
The sources of uncertainty—­can they be
addressed, and how?
When dentists have acknowledged the existing uncer-
tainty in managing root filled teeth with persisting api-
cal periodontitis, the search for the source of uncertainty
can begin. Seeing the difference between various origins
of uncertainty can be challenging, especially for a cli-
nician in their early career (Fox, 1957). Various strat-
egies can be adopted depending on the source of the
uncertainty. When the uncertainty is external/aleatory,
stemming from complexity, a tempting solution could
be to add more information for example by using ad-
ditional diagnostic tools, such as cone beam computed
tomography (CBCT). But the problem is that adding
more diagnostic methods does not always overcome the
uncertainty, that is, one test often leads to more tests,
adding more diagnostic uncertainty (Jha, 2014). In the
case with CBCT, it has been reported that the method
is less accurate for detecting periapical bone destruc-
tion associated with root filled teeth, with lower sen-
sitivity as well as specificity compared to when it is
applied to untreated teeth (Kruse et al., 2019). The low
positive predictive value (0.48–­0.65) suggests that the
presence of apical periodontitis in root filled teeth may
 |
286   
F I G U R E 2 Uncertainty may exist in several domains. This
drawing of a root filled tooth and its radiographic appearance
illustrates a clinical case but is merely used as an example—­the
periapical appearance could be more, or less, pronounced. The
patient experiences no symptoms. To one dentist, no feelings of
uncertainty are evoked when asked how to manage the tooth.
Regarding the exact same case, another dentist may feel uncertain
and be comfortable with acknowledging it. A few examples of
different dimensions of their uncertainty are suggested. (Drawing
borrowed from Ørstavik et al., 1986, with permission)
be systematically overestimated when CBCT is used
(Kruse et al., 2019). CBCT has also been suggested to
overestimate the frequency of post-­treatment disease
(Christiansen et al., 2009). Worth noting is that in com-
parison, the positive predictive value of intraoral peri-
apical radiography is actually reported to be somewhat
higher (0.67–­0.75), although data specifically on root
filled teeth is lacking (Brynolf, 1970; SBU, 2010). This
emphasizes the need to consider carefully whether an
available additional diagnostic measure has potential to
decrease uncertainty, or whether it may increase it. In
addition, low level of tolerance for uncertainty in medi-
cal primary care has been associated with higher costs
for care due to increased and unnecessary investigations
being undertaken (Allison et al., 1998). Instead, a use-
ful strategy may be to critically assess the underlying
assumptions that we use when we think about various
consequences to allow a strategy to take informed action
to be developed. As a scaffold or framework, it may be
useful to think in terms of benefits, costs, and risks of
different paths of action.
One internal/epistemic source of uncertainty could be
the limitations in the clinician's own knowledge. If the
dentist does not know how to interpret a radiograph or
13652591, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13679 by Cochrane Sweden, Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
UNCERTAINTY IN ENDODONTICS
is inexperienced in endodontic diagnostics, the solution
could be additional training, for example, to reflect on
the subject with a colleague. This takes time and studies
have found that time is crucial for clinicians to engage in
reflection (Jonas-­Dwyer et al., 2013; Nasseripour et al.,
2021). To facilitate the ability for clinicians to deal with
uncertainty not only as novices but throughout their ca-
reers, the structures around them, for instance their em-
ployers, need to support them (Wooster & Maniate, 2019).
Another internal/epistemic source of uncertainty
is the recognition that the available information is in-
complete. Information can be incomplete because full
information is simply not available, that is, knowledge is
lacking. In endodontics, it is well established that there
is insufficient scientific evidence supported by quality
data in many areas, including diagnostics regarding
periapical status in general and particularly in relation
to root filled teeth (Bergenholtz & Kvist, 2013; Duncan
et al., 2016; Pigg et al., 2021; SBU, 2010). But informa-
tion can also be incomplete because the clinician is not
fully informed of the knowledge that is actually avail-
able. Despite, or perhaps due to, the rapid advances in
science and constant changes in the standard of care,
sources of uncertainty will always remain to some de-
gree; in other words, it is increasingly difficult for the in-
dividual to keep up with developments in terms of new
knowledge, skills, equipment, and procedures (Wooster
& Maniate, 2019). By becoming specialized in a field, for
example, Endodontology, the range of potential uncer-
tainty that one has to deal with in clinical practice is
reduced (Fox, 1957).
Consequences of uncertainty and how to
value them
So how should one think when assessing the risk for
exacerbation to occur from a root filled tooth with per-
sistent apical periodontitis—­and what measures should
one take given a balanced attitude towards uncertainty?
The position of extreme caution would be to extract all
root filled teeth with persistent apical periodontitis and
thereby eliminating any risk of future consequences
caused by infection from these teeth. This was popular in
the era of the “focal infection theory”, in the beginning
of the 20th century when Endodontology was almost
removed from the dental curricula (Gulabivala et al.,
2014). Less extreme but still action-­focused approaches
have been suggested; in his classical work, Strindberg
(1956) proposed a system where he recommended de-
ciding on retreatment or extraction upon diagnosing
a new or a persistent periapical lesion. In the 1980s,
Reit and Gröndahl (1984) recognized the possibility of

PIGG et al.
inaction by proposing a decision tree with the alterna-
tives no treatment, wait and see, extraction, surgical re-
treatment, and nonsurgical retreatment. Subsequently,
Kvist (2001) suggested adding subjective values to the
decision process by adding the principles: respect for pa-
tient autonomy, treatment risks, and the monetary costs
for retreatment.
Perhaps a reasonable goal is to find a middle ground,
balancing between on the one hand the probability of an
exacerbation of apical periodontitis occurring and the ac-
companying risk for consequences of varying nature and
severity such as pain, local or systemic spread of infection,
and tooth loss, and on the other hand the economic issues
associated with endodontic treatment or need of replace-
ment of an extracted tooth. The probability of experiencing
an exacerbation and the risk of serious consequences will
vary from case to case and information from clinical stud-
ies about the factors predicting exacerbation are lacking.
The possible paths of action alternatives include additional
diagnostics, watchful waiting, orthograde or retrograde
retreatment, and extraction. Serious consequences could
include different scenarios from life-­threatening spread of
infection to an impaired quality of life caused by the loss
of an anterior tooth. If the probability for exacerbation is
very low but the consequences if it occurs are severe, such
as in a patient with intravenous bisphosphonate treat-
ment, or with a history of radiation in the orofacial region,
one might decide on treatment to further reduce the risk.
In contrast, in a systemically healthy patient for which no
events that would merit a more vigilant attitude are antic-
ipated and with the same probability of an exacerbation, it
may be more reasonable to adopt the watchful waiting ap-
proach. The patient must have the final say in the decision
after being informed about the risk of consequences and
the risks involved in treatment as well as in no treatment
and about the overall uncertainty. One can assume that
the patient's own feelings of comfort or discomfort with
uncertainty will influence the decision to treat or not to
treat and the choice of treatment alternative.
When and how do dentists learn to manage
uncertainty? Implications for education
What, then, can be done to increase dentists’ awareness of
uncertainty, improve their management of it, and reduce
their feelings of discomfort with the situation? How, and
when, do dentists acquire their approach to situations
with inherent uncertainty? Concern has been raised that
the culture of certainty in the dental profession starts dur-
ing undergraduate education (von Bergmann & Shuler,
2019). The implications are interesting from several
perspectives. As previously mentioned, intolerance to
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   287
uncertainty is associated with increased rates of anxiety
(Kuhn et al., 2009), a state that in turn correlates with re-
duced academic achievement in students (Pekrun et al.,
2002). Thus, early training of students in the health profes-
sions to accept and manage the inevitable issues of ambi-
guity might improve their academic performance as well
as prepare them for their future clinical practice (White
& Williams, 2017). Strategies for managing uncertainty in
clinical practice can vary depending on how the clinical
instructors acted during the clinical education. Clinicians
trained in an environment where uncertainty is consid-
ered a problem that needs to be overcome tend to adopt
the same manner of thinking about uncertainty (Bochatay
& Bajwa, 2020) and are prone to display a manner of certi-
tude even when they do not actually feel certain. To avoid
this development and instead strive to instil comfort with
being uncertain, teachers can openly acknowledge their
own perceptions of uncertainty and show that they are
willing to reflect together with students. At first, it may be
challenging and difficult for both students and teachers to
reveal feelings of uncertainty but examining the sources
and issues of uncertainty can potentially deepen students
understanding of the subject and be helpful in their pro-
fessional life. As with other applications of critical think-
ing, targeted exercises can be designed to make reflection
a part of every clinical session (Botelho & Bhuyan, 2021;
Kuhn, 1999; Lee & Ryan-­Wenger, 1997).
One important issue when discussing how dentists
learn to manage uncertainty in endodontics and in den-
tistry in general is that learning outcomes and curricula
should reflect that knowledge about and ability to manage
uncertainty are desired outcomes. Programmes should
thus incorporate these competencies into course objec-
tives, learning activities and assessment; all according to
the principles of constructive alignment (Biggs & Tang,
2011). In the same way as students are encouraged to ac-
cept uncertainty as inevitable when teachers and instruc-
tors deal with uncertainty in a straightforward manner in
front of them (Fox, 1957), experts in the field, for example,
endodontists and endodontic researchers should act as
role models by acknowledging uncertainty as an unavoid-
able component of a complex discipline and inspire den-
tists as a group to do the same.
CON CLU SI ON S
Uncertainty exists in many domains within medicine
and dentistry, and endodontics is no exception. Using
persistent apical periodontitis associated with a root
filled tooth as an example, various types (or dimen-
sions) of uncertainty have been discussed, as well as
how identifying the source and issue of uncertainty in
 |
288   
different clinical cases may be helpful to the dentist
by providing guidance on how the uncertainty may be
managed, for example, indicating whether additional
diagnostic procedures will be helpful or when improv-
ing one's personal knowledge is a possible remedy.
Dentists’ awareness and thought processes may be
helped by open discussion about what we do not know,
on different levels. Openness of discussion and reflec-
tion within our discipline and especially within dental
education is likely helpful to improve dentists’ comfort
with decision-­making and subsequent action when they
are uncertain, but this remains to be tested in empirical
studies involving students and clinical practitioners.
AC KNOWLEDGEME NT S
The authors thank Dr. Dag Ørstavik for the courtesy of in-
cluding a line drawing from the Periapical Index (PAI) in
a figure in this paper. Original image: Dr. Ingrid Brynolf.
CO NF LICT OF INTE REST
The authors have no conflicts of interests in connection
with this article.
ETH ICAL A PPROVAL
This research did not require ethical review, since it is a
theoretical discussion paper.
AUTHOR CONT RIBU TION S
The authors all contributed to the ideas and design of this
research and to the drafting of the article.
O RC ID
Maria Pigg https://orcid.org/0000-0002-7989-1541
Joséphine Brodén https://orcid.org/0000-0001-9300-2520
Helena Fransson https://orcid.org/0000-0003-4290-2283
Niklas Vareman https://orcid.org/0000-0003-1758-6645
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How to cite this article: Pigg, M., Brodén, J.,
Fransson, H. & Vareman, N. (2022) How do we and
how should we deal with uncertainty in endodontics?
International Endodontic Journal, 55, 282–­289.
Available from: https://doi.org/10.1111/iej.13679