The large variations observed in dentists' management of periapical lesions in endodontically treated teeth suggest that disease concepts used in clinical practice should be investigated. In the present study it was hypothesized that dentists regard various periapical conditions as different stages on a health continuum. Variations could then be regarded as the result of the individuals selection of differing cut-off points for prescribing retreatment. The hypothesized decision-making model was tested using dental students in Amsterdam (Holland), Gothenburg (Sweden) and Pavia (Italy). The students were shown six simulated cases among which the quality of root filling seal and presence of post and crown were systematically varied. For each case, management of five periapical conditions was assessed. Five options were offered: no therapy, wait-and-see, nonsurgical retreatment, surgical retreatment, and extraction. For each examiner and case a 'retreatment preference score (RPS)' was established. The investigation showed large interindividual variations in RPS. A statistically significant higher mean RPS was seen among students in Pavia compared with students in Amsterdam and Gothenburg. Among all observers and cases it was found that if retreatment was proposed for a certain size of lesion, retreatment was subsequently selected for all larger lesions. The experiment gave evidence in support of the proposed hypothesis. The data also suggest that the choice of retreatment criterion is affected by values, costs of retreatment and technical quality of the original treatment.
The application of evidence-based dentistry to diagnosis should result in a reduction of errors in decision making. The frequency of errors is dependent not only on the accuracy of a diagnostic test for pathology, but also on the prior chance of disease being present. If this chance is low and below a certain threshold, then, for example, applying a diagnostic test can result in more decision errors and therefore inappropriate treatment than omitting to use the test. In deciding on the usefulness of a diagnostic test an additional factor to take into account is the relative value of the possible health states resulting from diagnosis and subsequent therapy. These can be determined by eliciting from the patient the numerical values of the possible dental health conditions using a visual analogue scale technique. Clinical decision analysis can then be carried out to calculate the most appropriate diagnostic strategy for the patient. Clinical decision analysis is starting to influence the development of guidelines for the diagnostic use of radiographs although its application in dentistry needs further refinement and development.
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