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

BACKGROUND: The outcome of endodontic treatment is generally assessed using a range of patient and clinician-centred, non-standardised clinical and radiographic outcome measures. This makes it difficult to synthesise evidence for systematic analysis of the literature and the development of clinical guidelines. Core outcome sets (COS) represent a standardised list of outcomes that should be measured and reported in all clinical studies in a particular field. Recently, clinical researchers and guideline developers have focussed on the need for the integration of a patient-reported COS with clinician-centred measures. This study aims to develop a COS that includes both patient-reported outcomes and clinician-centred measures for various endodontic treatment modalities to be used in clinical research and practice. METHODS: To identify reported outcomes (including when and how they are measured), systematic reviews and their included clinical studies, which focus on the outcome of endodontic treatment and were published between 1990 and 2020 will be screened. The COSs will be defined by a consensus process involving key stakeholders using semi-structured interviews and an online Delphi methodology followed by an interactive virtual consensus meeting. A heterogeneous group of key 'stakeholders' including patients, general dental practitioners, endodontists, endodontic teachers, clinical researchers, students and policy-makers will be invited to participate. Patients will establish, via interactive interviews, which outcomes they value and feel should be included in a COS. In the Delphi process, other stakeholders will be asked to prioritise outcomes identified from the literature and patient interviews and will have the opportunity at the end of the first round to add outcomes that are not included, but which they consider relevant. Feedback will be provided in the second round, when participants will be asked to prioritise the list again. If consensus is reached, the remaining outcomes will be discussed at an online meeting and agreement established via defined consensus rules of outcome inclusion. If consensus is not reached after the second round, a third round will be conducted with feedback, followed by the online meeting. Following the identification of a COS, we will proceed to identify how and when these outcomes are measured. DISCUSSION: Using a rigorous methodology, the proposed consensus process aims to develop a COS for endodontic treatment that will be relevant to stakeholders. The results of the study will be shared with participants and COS users. To increase COS uptake, it will also be actively shared with clinical guideline developers, research funders and the editors of general dental and endodontology journals. TRIAL REGISTRATION: COMET 1879. 21 May 2021.

Comparison of a commercial real-time PCR panel to routine laboratory methods for the diagnosis of meningitis-encephalitis.

Meningitis-encephalitis can range from a mild, self limiting illness to a life threatening disease. Rapid microbial diagnosis allows for early targeted management. This study aimed to compare the BioFire FilmArray Meningitis/Encephalitis multiplex PCR panel (ME panel) to traditional testing algorithms for accuracy and turnaround time in the diagnosis of meningitis-encephalitis. From April to November 2018, cerebrospinal fluid (CSF) samples meeting existing laboratory testing criteria for suspected community acquired meningitis-encephalitis were tested on the ME panel and by routine laboratory methods. The methods were compared for accuracy of diagnosis and turnaround time. Where an organism was not identified, the study investigators came to a consensus on whether an infective aetiology was likely based on CSF parameters, clinical features, management and final discharge diagnosis. A total of 147 CSF samples met criteria for testing. Results were concordant in 143 (97%) of cases, including 27 samples where the same organism was identified by both methods. Of the four discordant samples, three organisms identified by the ME panel alone were considered clinically insignificant. One sample, which was culture and antigen positive for Cryptococcus neoformans, was not detected on the ME panel. The ME panel and routine methods identified an organism in 55% and 58% of clinically compatible cases of infection, respectively. The median turnaround time for the ME panel was 2.9 hours, compared to 21.1 hours for routine testing. The ME panel showed high concordance with traditional testing, simplified laboratory workflow, and significantly reduced turnaround time. The failure of the ME panel to detect Cryptococcus spp. is concerning. When cryptococcal meningitis is suspected, we would recommend using culture and cryptococcal antigen testing as the investigations of choice. Despite the availability of molecular assays targeting the common causes of CNS infection, the diagnostic yield remains suboptimal.

Comparison of two case difficulty assessment methods on cohorts of undergraduate dental students - a multi-centre study.

AIM: To compare the educational benefits and user friendliness of two anonymized endodontic case difficulty assessment (CDA) methods. METHODOLOGY: A cohort (n = 206) of fourth-year undergraduate dental students were recruited from four different Dental Schools and divided randomly into two groups (Group A and B). The participants assessed six test endodontic cases using anonymized versions of the American Association of Endodontists (AAE) case difficulty assessment form (AAE Endodontic Case Difficulty Assessment Form and Guidelines, 2006) and EndoApp, a web-based CDA tool. Group A (n = 107) used the AAE form for assessment of the first three cases, followed by EndoApp for the latter. Group B (n = 99) used EndoApp for the initial three cases and switched to the AAE form for the remainder. Data were collected online and analysed to assess participants' knowledge reinforcement and agreement with the recommendation generated. Statistical analysis was performed using the two-way mixed model anova, Cohen's Kappa (κ) and independent t-tests, with the levels of significance set at P < 0.05. Additionally, participants' feedback and preference for CDA was also gathered. RESULTS: There was a significant increase in knowledge reinforcement for the AAE form and EndoApp (P = 0.001) after assessment of the first three test cases. However, this increase was not significant (P = 0.842) between the CDA methods. Overall, the AAE form and EndoApp had slight (κ = 0.176, P < 0.001) and substantial (κ = 0.668, P < 0.001) levels of agreement, respectively, and the difference was statistically significant (P < 0.001). Participants' feedback on user friendliness favoured EndoApp for all parameters measured. EndoApp was preferred by 65% of the cohort, whereas only 11% chose the AAE form for CDA. CONCLUSIONS: Both the AAE form and EndoApp were beneficial for dental education. EndoApp was reliable in helping with decisions to treat or refer, and combined with user friendliness, it was the preferred choice for CDA.

PRICE 2020 guidelines for reporting case reports in Endodontics: explanation and elaboration.

Case reports play a key role in showcasing new, unusual or rare disease(s), and the impact of newer therapeutic approaches or interventions. The Preferred Reporting Items for Case reports in Endodontics (PRICE) 2020 guidelines are being introduced exclusively for Endodontics by adapting and integrating the CAse REport (CARE) guidelines and Clinical and Laboratory Images in Publications principles. The PRICE 2020 guidelines have been developed to help authors improve the completeness, accuracy and transparency of case reports in Endodontics and thus enhance the standard of manuscripts submitted for publication. The aim of this document is to provide a comprehensive explanation for each item in the PRICE 2020 checklist along with examples from the literature that demonstrate compliance with these guidelines. This information will highlight the importance of each item and provide practical examples to help authors understand the necessity of providing comprehensive information when preparing case reports. A link to this PRICE 2020 explanation and elaboration document is available on the Preferred Reporting Items for study Designs in Endodontology website at http://www.pride-endodonticguidelines.org.

PRICE 2020 guidelines for reporting case reports in Endodontics: a consensus-based development.

Case reports can provide early information about new, unusual or rare disease(s), newer treatment strategies, improved therapeutic benefits and adverse effects of interventions or medications. This paper describes the process that led to the development of the Preferred Reporting Items for Case reports in Endodontics (PRICE) 2020 guidelines through a consensus-based methodology. A steering committee was formed with eight members (PD, VN, BC, PM, PS, EP, JJ and SP), including the project leaders (PD, VN). The steering committee developed an initial checklist by combining and modifying the items from the Case Report (CARE) guidelines and Clinical and Laboratory Images in Publications (CLIP) principles. A PRICE Delphi Group (PDG) and PRICE Face-to-Face Meeting Group (PFMG) were then formed. The members of the PDG were invited to participate in an online Delphi process to achieve consensus on the wording and utility of the checklist items and the accompanying flow chart that was created to complement the PRICE 2020 guidelines. The revised PRICE checklist and flow chart developed by the online Delphi process was discussed by the PFMG at a meeting held during the 19th European Society of Endodontology (ESE) Biennial Congress in Vienna, Austria, in September 2019. Following the meeting, the steering committee created a final version of the guidelines, which were piloted by several authors during the writing of a case report. In order to help improve the clarity, completeness and quality of case reports in Endodontics, we encourage authors to use the PRICE 2020 guidelines.

Guidelines for reporting the quality of clinical case reports in Endodontics: a development protocol.

Case reports are used to communicate interesting, new or rare condition/s, innovative treatment approaches or novel techniques. Apart from informing readers, such information has the potential to contribute towards further scientific studies and the development of newer management modalities. In that context, it is important that case reports are presented accurately and deliver all the necessary and pertinent information to the reader. Reporting guidelines are used to inform authors of the quality standards required to ensure their manuscripts are accurate, complete and transparent. The aim of this project is to develop and disseminate new guidelines - Preferred Reporting Items for Case reports in Endodontics (PRICE). The primary aim is to aid authors when constructing case reports in the field of Endodontics to ensure the highest possible reporting standards are adopted. The project leaders (PD and VN) formed a steering committee comprising six additional members. Subsequently, a five-phase consensus process will be used. The steering committee will develop the PRICE guidelines (PRICE checklist and flow chart) by identifying relevant items (quality standards) derived from the CAse REport guidelines and Clinical and Laboratory Images in Publications principles, focussing on the content of case reports. Following this, the steering committee will identify a PRICE Delphi Group (PDG) consisting of 30 members including academicians, practitioners, and members of the public. The individual items (components) of the PRICE checklist will be evaluated by the PDG based on a 9-point Likert scale. Only items scored between 7 and 9 by 70% or more members will be included in the draft checklist. The Delphi process will be continued until a consensus is reached and a final set of items agreed by the PDG members. Following this, a PRICE Face-to-Face meeting group (PFMG) will be formed with 20 members to achieve a final consensus. The final consensus-based checklist and flow chart will be evaluated and approved by selected members of the PDG and PFMG. The approved PRICE guidelines will be published in relevant journals and disseminated via contacts in academic institutions and national endodontic societies, as well as being presented at scientific/clinical meetings.

3D imaging, 3D printing and 3D virtual planning in endodontics.

The adoption and adaptation of recent advances in digital technology, such as three-dimensional (3D) printed objects and haptic simulators, in dentistry have influenced teaching and/or management of cases involving implant, craniofacial, maxillofacial, orthognathic and periodontal treatments. 3D printed models and guides may help operators plan and tackle complicated non-surgical and surgical endodontic treatment and may aid skill acquisition. Haptic simulators may assist in the development of competency in endodontic procedures through the acquisition of psycho-motor skills. This review explores and discusses the potential applications of 3D printed models and guides, and haptic simulators in the teaching and management of endodontic procedures. An understanding of the pertinent technology related to the production of 3D printed objects and the operation of haptic simulators are also presented.

A web-based endodontic case difficulty assessment tool.

OBJECTIVE: To develop a web-based tool to facilitate identification, evaluation and management of teeth requiring endodontic treatment. MATERIALS AND METHODS: Following a literature search and thorough analysis of existing case difficulty assessment forms, the web-based tool was developed using an online survey builder (Qualtrics, Qualtrics Lab, UT, USA). Following feedback from a pilot study, it was refined and improved. A study was performed, using the updated version (EndoApp) on a cohort (n = 53) of dental professionals and dental students. The participants were e-mailed instructions detailing the assessment of five test cases using EndoApp, followed by completion of a structured feedback form. Analysis of the EndoApp responses was used to evaluate usage times, whereas the results of the feedback forms were used to assess user experience and relevance, other potential applications and comments on further improvement/s. RESULTS: The average usage time was 2 min 7 s; the average times needed for the last three (Cases 3-5) were significantly less than the preceding two (Cases 1 & 2) test cases. An overwhelming majority of participants expressed favourable views on user experience and relevance of the web-based case difficulty assessment tool. Only two participants (4%) were unlikely or very unlikely to use EndoApp again. The potential application of EndoApp as an 'educational tool' and for 'primary care triage' was deemed the most popular features and of greater importance than the secondary options of 'fee setting' and as a 'dento-legal justification tool'. CONCLUSIONS: Within the study limitations, owing to its ability to quantify the level of difficulty and provide guidance, EndoApp was considered user-friendly and helped facilitate endodontic case difficulty assessment. From the feedback, further improvements and the development of a Smartphone App version are in progress. CLINICAL RELEVANCE: EndoApp may facilitate treatment planning, improve treatment cost-effectiveness and reduce frequency of procedural errors by providing appropriate guidance on endodontic case management.

The quality of radiographs accompanying endodontic referrals to a health authority clinic.

AIM: To assess the quality of radiographs accompanying endodontic referrals, from general dental practitioners, to a health authority clinic. METHODS: A total of 200 conventional film and digital radiographs accompanying referrals were assessed and rated as 'excellent', 'diagnostically acceptable' or 'unacceptable' according to the National Radiographic Protection Board (NRPB) guidelines. Statistical analyses of the results included inter- and intra-observer agreement to achieve a kappa score and the chi-squared test. RESULTS: Out of the 200 radiographs assessed, 38 (19%) were conventional film and 162 (81%) were digital. Of the conventional film radiographs, 55% were rated 'excellent' and 37% were 'diagnostically acceptable', whilst 27% of digital radiographs were rated 'excellent' and 40% were 'diagnostically acceptable'. In the 'unacceptable' category, 33% were digital and 8% were conventional film radiographs (p <0.001). CONCLUSIONS: The quality of digital radiographs was significantly lower compared with conventional film radiographs. The percentage of 'unacceptable' digital radiographs was above the target according to the NRPB guidelines. Hence, there is a need for improvement in quality to avoid repeat radiographs and unnecessary ionising radiation exposure. Instead of hard, printed copies, digital radiographs accompanying referrals should, within the parameters of information governance, be supplied electronically so that they may be optimised, if necessary, for better diagnostic value.

The anatomical relationship between the roots of mandibular second molars and the inferior alveolar nerve.

AIM: To evaluate the anatomical relationship between the roots of mandibular second molars and the inferior alveolar nerve (IAN) in relation to the risk of potential nerve injury during root canal treatment. METHODOLOGY: Cone-beam computed tomography (CBCT) images from the patient record database at a dental hospital were selected. The anonymized CBCT images were reconstructed and examined in three planes (coronal, axial and sagittal) using 3D viewing software. The relationship between each root apex of mandibular second molars and the IAN was evaluated by measuring the horizontal and vertical distances from coronal CBCT sections, and the actual distance was then calculated mathematically using Pythagoras' theorem. RESULTS: In 55% of the 272 mandibular second molar roots evaluated, from a total of 134 scans, the distance between the anatomical root apex and the IAN was ≤3 mm. CONCLUSIONS: In over 50% of the cases evaluated, there was an intimate relationship between the roots of mandibular second molars and the inferior alveolar nerve (IAN). Therefore, root canal treatment of mandibular second molars may pose a more significant potential risk of IAN injury; necessary precautions should be exercised, and the prudent use of CBCT should be considered if an intimate relationship is suspected.

Apical periodontitis and the technical quality of root canal treatment in an adult sub-population in London.

AIM: To assess the prevalence of apical periodontitis (AP) and the technical quality of root canal treatment in an adult sub-population in London. METHODOLOGY: Panoramic radiographs of 136 patients who attended a dental hospital were collected. The periapical health of teeth present was assessed radiographically and the presence or absence of AP noted. The technical quality of the root canal treatment was scored as adequate or inadequate, based on the European Society of Endodontology (2006) guidelines. RESULTS: A total of 3,396 teeth were assessed; AP was detected in 4.1% of the teeth. Forty-nine percent of patients had at least one tooth with radiographic evidence of AP. The percentage of root filled teeth with AP was 38.3%. AP was significantly more frequently found in root treated, compared with non-root treated, teeth (p <0.001). In 44.3% of the cases, the technical quality of the root canal filling was inadequate. AP was detected in 14% of adequately, compared with 68.6% of inadequately, root filled teeth. There is a significant negative correlation between the technical quality of root canal treatment and the presence of AP (p <0.001). CONCLUSIONS: There was a high prevalence of AP and poor technical quality root canal treatment; a strong association between AP and root filled teeth, and between the periapical health and the technical quality of the root canal treatment. The results are consistent with previous studies using similar methodology and re-confirmed that high technical quality root canal treatment is crucial to ensure a favourable treatment outcome.

Endodontic surgery.

A better understanding of endodontic disease and the causes of treatment failure has refined the role of surgery in endodontics. The advent of newer materials, advances in surgical armamentarium and techniques have also led to an improved endodontic surgical outcome. The aim of this article is to provide a contemporary and up-to-date overview of endodontic surgery. It will focus primarily on the procedures most commonly performed in endodontic surgery.