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

AIM: To determine and explain the principal sources of stress among preclinical and clinical dental undergraduate students with a particular focus on the stressors linked to endodontics. METHODOLOGY: A mixed-methods study, with an explanatory sequential design, was employed. Volunteer students of second, third and fourth years were asked to complete both the Dental Environment Stress (DES) questionnaire and a bespoke questionnaire for endodontic-related stress assessment, which had 21 questions in common with the DES. The results were analysed by Kruskal-Wallis and Marginal Homogeneity tests. In the second part of the study, a qualitative phase was conducted through focus group interviews of students from each academic year included in the study. Interviews were analysed by inductive content analysis. RESULTS: The DES questionnaire determined that for all years the most stressful domains were 'performance pressure', 'workload' and 'clinical training'. According to the endodontic stress questionnaire, the most stressful domains were 'self-efficacy beliefs', 'endodontic clinical training' and 'faculty and administration' in early years, while they were 'endodontic patient treatment', 'performance pressure in endodontics' and 'clinical training' in later years. Comparing questions common to both questionnaires revealed that the stress score was lower for the endodontic stress questionnaire than in the DES questionnaire for 17 questions, being significantly lower for 13 questions (p < 0.05) and significantly higher for no question. The qualitative study showed that students' dental and endodontic-related stress was linked to different domains: patient, clinical procedure, organization, staff, academic education, evaluation and COVID-19-related issues. Qualitative aspects highlighted the important role that patients and COVID-19 have played in student stress. However, they suggested a possible explanation for the lower endodontic stress observed in this dental university hospital, which was based on: the nature of the teaching in endodontics, the consensus between endodontic supervisors, the use of a logical, progressive procedure and the considerable experience that students gain over the years. CONCLUSION: Students considered endodontics stressful; however, education can play a central role in reducing stress, particularly during the early parts of the undergraduate course.

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

AIM: To evaluate sources of student confidence and stress during the management of deep carious lesions and the exposed pulp during undergraduate clinics. Further aims were to identify barriers and facilitators, which could result in educational or practical improvements in the delivery of teaching and provision of treatment in this area. METHODOLOGY: A exploratory qualitative study design was used, based on recorded focus group interviews, guided by 12 predetermined questions. The discussions were transcribed verbatim and analysed by inductive qualitative content analysis. Common categories were identified to aid understanding. Forty undergraduate dental students from 4th and 5th years in Dublin Dental University Hospital participated in the study. RESULTS: Student stress and confidence were multifactorial and broadly linked to specific domains: clinical procedure, academic education, clinical training, evaluation/grading, organization and equipment, vital pulp biomaterial and the patient. Most students expressed a preference for one-stage selective carious removal to soft dentine rather than potential pulp exposure in deep carious lesions, noting that although it helped to decrease their immediate stress, it also caused longer-term concern by leaving caries close to the pulp. Nevertheless, their confidence was affected by limited clinical experience of carrying out selective removal procedures in deep caries. A recurrent finding was students citing high levels of stress after pulp exposure. Feelings including anger, fear, embarrassment and denial were associated with pulp exposure during deep caries management. Generally, the students felt able to manage pulp capping procedures, but were less certain about partial pulpotomy, suggesting that although they are aware of its advantages, they were unsure about the appropriate volume of pulp tissue to remove. To reduce stress, students suggested that laboratory teaching should employ new 3-D printed solutions and clinics should establish clear consensus amongst supervising teachers about the best way to manage the exposed pulp. CONCLUSIONS: Students lacked confidence as they neared the pulp and prefer selective caries removal techniques, which reduce the likelihood of pulp exposure. Students identified stressors and suggested improvements in several domains that would improve confidence. These ameliorations could lead to enhancements in student ability to perform these conservative techniques, and improve the provision of treatment in this area.

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

AIMS: To investigate and compare views on management of deep caries and the exposed pulp by Endodontic Society members in Ireland (Irish Endodontic Society [IES]) and Italy (Accademia Italiana di Endodonzia [AIE]). Further aims were to investigate the influence of patient-related factors (age, symptoms) and operator-related factors (material choice, antibiotics) on management. METHODOLOGY: A structured online questionnaire containing two cases (an 18- and 45-year-old) and two scenarios (± mild symptoms), including history and radiograph, was sent to IES and AIE members. The answers were analysed using chi-square and Fisher's exact test (P < 0.05). RESULTS: In total, 120 dentists participated, representing 49% of the AIE and 48% of the IES membership. Age distribution was similar between the societies; however, most AIE members had no further qualifications (63%), while IES respondents generally had a postgraduate endodontic qualification (71%). AIE respondents carried out a larger volume of vital pulp treatment (VPT) per month, with 69% carrying out over five cases, compared with 22% of IES respondents. The presence of patient symptoms significantly altered treatment planning decisions (P < 0.001) with root canal treatment (RCT) more frequently selected in both societies. Patient age significantly influenced treatment choice in the absence (P = 0.043) or presence (P = 0.012) of symptoms with less VPT advocated in older patients. There were no significant differences in the treatment of a young patient in the presence (P = 0.302) or absence of symptoms (P = 0.297); however, older patient management differed between the societies for symptomatic (P = 0.041) and asymptomatic scenarios (P = 0.044) with significantly more RCTs carried out in the AIE than the IES. Hydraulic calcium silicate materials were commonly selected, accounting for 81% of IES and 69% of AIE VPT materials, although younger members of the AIE preferred calcium hydroxide materials. Younger dentists in both societies prescribed less RCT than older age groups. CONCLUSIONS: Although VPT is carried out by members of both societies there was no consistency regarding the most appropriate management for the exposed pulp or the VPT material of choice. Patient symptoms and age significantly influence the decision-making process and invasiveness of treatment. Hydraulic calcium silicate materials were the most commonly advocated material in all groups except young AIE members who preferred calcium hydroxide.

Glossary for randomized clinical trials.

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

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

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

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

AIM: To critically evaluate the reporting quality of a random sample of clinical trials published in Endodontics against the PRIRATE 2020 checklist and to analyse the association between the quality of reported trials and a variety of parameters. METHODOLOGY: Fifty randomized clinical trials relating to Endodontics were randomly selected from the PubMed database from 2015 to 2019 and evaluated by two independent reviewers. For each trial, a score of '1' was awarded when it fully reported each item in the PRIRATE guidelines whereas a score of '0' was awarded when an item was not reported; when the item was reported inadequately a score of '0.5' was awarded. For the items that were not relevant to the trial, 'Not Applicable (NA)' was given. Based on the interquartile range of the overall scores received, trials were categorized into 'Low' (0-58.4%), 'Moderate' (58.5-72.8%) and 'High' (72.9-100%) quality. The associations between characteristics and quality of clinical trials were investigated. Descriptive statistics, frequency analysis and percentage analyses were used to describe the data. To determine the significance of categorical data, the chi-square test was used. The probability value 0.05 was considered as the level of significance. RESULTS: Based on the overall scores, 13 (26%), 25(50%) and 12 (24%) of the reports of clinical trials were categorized as 'High', 'Moderate' and 'Low' quality, respectively. Three items (1b, 6d, 11e) were adequately reported in all manuscripts whilst two items (5k, 5m) were scored 'NA' in all the reports. The reports published from Europe had a significantly greater percentage of 'High'-quality scores, compared to Asia, Middle East, North America and South America (P = 0.0002). The 'High'-quality reports were published significantly more often in impact factor journals (P = 0.045). Reports of clinical trials published in journals that adhered to the CONSORT guidelines had significantly more 'High' scores compared to those that did not (P = 0.008). Clinical trials with protocols registered a priori had a significantly greater percentage of 'High' scores compared to the trials that were not registered in advance (P = 0.003). No significant difference occurred between the quality of clinical trials and the number of authors, journal (Endodontic specialty vs. Non-Endodontic specialty) or year of publication. CONCLUSIONS: Reports of randomized clinical trials published in the speciality of Endodontics had a substantial number of deficiencies. To create high-quality reports of clinical trials, authors should comply with the PRIRATE 2020 guidelines.

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

BACKGROUND: The association between adverse pregnancy outcomes (APOs) and maternal apical periodontitis remains unclear as it has not been examined rigorously or reviewed systematically. OBJECTIVE: To systematically review and critically evaluate the available evidence on the association of maternal apical periodontitis with several APOs. METHODS: A literature search was conducted using the following electronic databases: Clarivate Analytics' Web of Science, Scopus, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL), from inception to 25 February 2021, with no language restrictions. Observational studies including longitudinal clinical trials, cohort, case-control and cross-sectional studies of prospective and retrospective design were included. Articles with duplicate or overlapping results, abstract-only papers, case reports, case series, animal studies and reviews were excluded. Two independent reviewers were involved in study selection, data extraction and appraising the included studies; disagreements were resolved by a third reviewer. The Newcastle-Ottawa Scale (NOS) and the adapted form of the NOS were used to assess the quality for case-control and cross-sectional studies, respectively. RESULTS: Two case-control and one cross-sectional study were included in the current review. The included studies were published between 2015 and 2017, with a total of 1187 participating individuals with an approximate age range of 15 to 40 years. As the included studies reported different outcomes, the heterogeneity of data prevented a meta-analysis being undertaken. The overall quality of the evidence was 'Fair' for two out of three included studies, while one study was categorized as 'Good'. DISCUSSION: Two out of three included primary studies had a substantial number of methodological inconsistencies and flaws, and therefore caution should be exercised in interpreting the results of this systematic review because several important covariates were not considered in the original investigations. CONCLUSION: Based on a limited volume and 'Fair' and 'Good' quality of evidence, a positive association between maternal apical periodontitis and APOs was observed. However, more 'Good' quality clinical studies are needed to confirm the results of the current review. FUNDING: None REGISTRATION: PROSPERO database (CRD42-2191987).

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

BACKGROUND: The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis. OBJECTIVES: To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome. METHODS: Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality. RESULTS: Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine. DISCUSSION: These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI. CONCLUSIONS: Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.

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

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

Association between cardiovascular diseases and apical periodontitis: an umbrella review.

BACKGROUND: The existence of an association between cardiovascular diseases (CVDs) and apical periodontitis (AP) remains unclear because results obtained from previous clinical studies and reviews are inconsistent or inconclusive. OBJECTIVE: To conduct an umbrella review to determine whether there is an association between CVDs and the prevalence of AP in adults. METHODS: The protocol of the review was registered in the PROSPERO database (CRD42020185753). The literature search was conducted using the following electronic databases: Clarivate Analytics' Web of Science Scopus, PubMed and Cochrane Database of Systematic Reviews, from inception to May, 2020, with no language restrictions. Systematic reviews with or without meta-analysis that evaluated the association between CVDs and AP were included. Other types of studies, including narrative reviews, were excluded. Two reviewers independently performed a literature search, data extraction and quality assessment of included studies. Any disagreements or doubts were resolved by a third reviewer. The quality of the reviews was assessed using the AMSTAR 2 tool (A measurement tool to assess systematic reviews), with 16 items. A final categorization of the systematic reviews classified each as of 'high', 'moderate', 'low' or 'critically low' quality. RESULTS: Four systematic reviews were included in the current review. Three reviews were graded by AMSTAR 2 as 'moderate' quality, whereas one review was graded as 'critically low' quality. DISCUSSION: Only one systematic review included a meta-analysis. Substantial heterogeneity amongst the primary studies included within each systematic review was notable in preventing a pooled analysis. CONCLUSIONS: From the limited 'moderate' to 'critically low' quality evidence available, the current umbrella review concluded that a weak association exists between CVDs and AP. In the future, well-designed, longitudinal clinical studies with long-term follow-up are required.

PRIRATE 2020 guidelines for reporting randomized trials in Endodontics: explanation and elaboration.

Well-designed and properly conducted randomized clinical trials provide a true estimate of the effects of interventions and are acknowledged as the gold standard in terms of clinical study design. However, the quality of randomized clinical trials published in the field of Endodontics is suboptimal. The Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 guidelines were developed exclusively for Endodontics by integrating and adapting the CONsolidated Standards of Reporting Trials (CONSORT) statement and Clinical and Laboratory Images in Publications (CLIP) principles, through an accepted and well-documented consensus process. Full implementation of the PRIRATE 2020 guidelines will minimize potential sources of bias and thus enhance the standard of manuscripts submitted for publication, which will ultimately improve the reporting of randomized clinical trials in Endodontics. The aim of this document is to provide an explanation for each item in the PRIRATE 2020 checklist and flowchart with examples from the literature in order to help authors understand their rationale and significance. A link to this PRIRATE 2020 explanation and elaboration document is available on the Preferred Reporting Items for study Designs in Endodontology (PRIDE) website at http://www.pride-endodonticguidelines.org/prirate/.

Glossary for systematic reviews and meta-analyses.

A systematic review aims to answer a focussed research question through a structured review of the evidence, using a predefined methodology, which often includes a meta-analysis. A meta-analysis is a statistical method used to combine the effect estimates from the individual studies included in a systematic review. Systematic reviews and meta-analyses are positioned at the highest level in the hierarchy of clinical evidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was introduced in 2009 to help authors improve the quality and reliability of systematic reviews and meta-analyses. Recently, the volume of systematic reviews and meta-analyses in the field of Endodontology has increased; however, the quality of the published manuscripts has been reported to be sub-optimal, which does not take account of the systematic reviews that were rejected because of more obvious deficiencies. The aim of this paper is to present a comprehensive glossary of terminology commonly used in systematic reviews and meta-analyses in an attempt to provide easily understood definitions and explanations to assist authors when reporting systematic reviews and meta-analyses and to allow those wishing to read them to become better informed.

Is articaine more effective than lidocaine in patients with irreversible pulpitis? An umbrella review.

BACKGROUND: Pain management can be challenging during root canal treatment of teeth with irreversible pulpitis. AIM: To identify whether articaine or lidocaine is the most appropriate local anaesthetic solution for teeth with irreversible pulpitis undergoing root canal treatment. DATA SOURCE: The protocol of this umbrella review is registered in the PROSPERO database (CRD42019137624). PubMed, EBSCHO host and Scopus databases were searched until June 2019. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Systematic reviews published in English comparing the effectiveness of local anaesthesia following administration of articaine or lidocaine in patients undergoing root canal treatment of teeth diagnosed with irreversible pulpitis were included. Two independent reviewers selected the studies and carried out the data extraction and the appraisal of the included reviews. Disagreements were resolved in consultation with a third reviewer. STUDY APPRAISAL AND SYNTHESIS METHODS: The quality of the included reviews was appraised by two independent reviewers using the AMSTAR tool (a measurement tool to assess systematic reviews). Each of the 11 AMSTAR items was given a score of 1 if the specific criterion was met, or 0 if the criterion was not met or the information was unclear. RESULTS: Five systematic reviews with meta-analyses were included. The AMSTAR score for the reviews ranged from 8 to 11, out of a maximum score of 11, and all reviews were categorized as 'high' quality. Two reviews scored 0 for item 8 in AMSTAR because the scientific quality of the clinical trials included in these reviews was not used in the formulation of the conclusions. LIMITATIONS: Systematic reviews published only in the English language were included. Only a small number of studies were available to assess pain intensity during the injection phase, the time until the onset of anaesthesia and the occurrence of adverse events. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Articaine is more effective than lidocaine for local anaesthesia of teeth with irreversible pulpitis undergoing root canal treatment. There is limited evidence that injection of articaine is less painful, has more rapid onset and has fewer adverse events compared with lidocaine.

PRIRATE 2020 guidelines for reporting randomized trials in Endodontics: a consensus-based development.

In evidence-based health care, randomized clinical trials provide the most accurate and reliable information on the effectiveness of an intervention. This project aimed to develop reporting guidelines, exclusively for randomized clinical trials in the dental specialty of Endodontology, using a well-documented, validated consensus-based methodology. The guidelines have been named Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020. A total of eight individuals (PD, VN, HD, LB, TK, JJ, EP and SP), including the project leaders (PD and VN) formed a steering committee. The committee developed a checklist based on the items in the Consolidated Standards of Reporting Trials (CONSORT) guidelines and Clinical and Laboratory Images in Publications (CLIP) principles. A PRIRATE Delphi Group (PDG) and PRIRATE Face-to-Face Meeting group (PFMG) were also formed. Thirty PDG members participated in the online Delphi process and achieved consensus on the checklist items and flowchart that make up the PRIRATE guidelines. The guidelines were discussed at a meeting of the PFMG at the 19th European Society of Endodontology (ESE) Biennial congress, held on 13 September 2019 in Vienna, Austria. A total of 21 individuals from across the globe and four steering committee members (PD, VN, HD and LB) attended the meeting. As a consequence of the discussions, the guidelines were modified and then piloted by several authors whilst writing a manuscript. The PRIRATE 2020 guidelines contain a checklist consisting of 11 sections and 58 individual items as well as a flowchart, considered essential for authors to include when writing manuscripts for randomized clinical trials in Endodontics.

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.

Preferred Reporting items for OBservational studies in Endodontics (PROBE) guidelines: a development protocol.

Observational studies have a significant role in establishing the prevalence and incidence of diseases in populations, as well as determining the benefits and risks associated with health-related interventions. Observational studies principally encompass cohort, case-control, case series and cross-sectional designs. Inadequate reporting of observational studies is likely to have a negative impact on decision-making in day-to-day clinical practice; however, no reporting guidelines have been published for observational studies in Endodontics. The aim of this project is to develop reporting guidelines for authors when creating manuscripts describing observational studies in the field of Endodontology in an attempt to improve the quality of publications. The new guidelines for observational studies will be named: 'Preferred Reporting items for OBservational studies in Endodontics (PROBE)'. A steering committee was formed by the project leaders (PD, VN) to develop the guidelines through a five-phase consensus process. The steering committee will review and adapt items from the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement and the Clinical and Laboratory Images in Publications (CLIP) principles, as well as identify new items that add value to Endodontics. The steering committee will create a PROBE Delphi Group (PDG), consisting of 30 members across the globe to review and refine the draft checklist items and flowchart. The items will be assessed by the PDG on a nine-point Likert scale for relevance and inclusion. The agreed items will then be discussed by a PROBE Face-to-Face meeting group (PFMG) made up of 20 individuals to further refine the guidelines. After receiving feedback from the PFMG, the steering committee will pilot and finalize the guidelines. The approved PROBE guidelines will be disseminated through publication in relevant journals, and be presented at national and international conferences. The PROBE checklist and flowchart will be available and downloadable from the Preferred Reporting Items for study Designs in Endodontics (PRIDE) website: www.pride-endodonticguidelines.org. The PROBE steering committee encourages clinicians, researchers, editors and peer reviewers to provide feedback on the PROBE guidelines to inform the steering group when the guidelines are updated.

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

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

Management of deep caries and the exposed pulp.

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

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

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

Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) guidelines: a development protocol.

Randomized clinical trials are acknowledged as the most appropriate methodology for demonstrating the efficacy or effectiveness of one intervention as opposed to another and thus play a major role in clinical decision-making. However, it is recognized that despite the existence of various guidelines, for example, the Consolidated Standards for Reporting Trials (CONSORT) statement, the quality of manuscripts describing randomized trials is often suboptimal. The current project aims to develop and disseminate new guidelines, Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE), to improve the planning and reporting quality of randomized trials in the field of Endodontics. The project leads (VN, PD) designed a robust process to develop the PRIRATE guidelines. At first, a steering committee of eight members, including the project leads, was formed. Thereafter, a five-stage consensus process will be followed: initial steps, pre-meeting activities, face-to-face consensus meeting, post-meeting activities and post-publication activities. The steering committee will develop the first draft of the PRIRATE guidelines by identifying relevant and important items from various sources including the CONSORT guidelines and the Clinical and Laboratory Images in Publications (CLIP) principles. This will be followed by the establishment of a PRIRATE Delphi Group (PDG) consisting of 30 members. The individual items of the first draft of the PRIRATE guidelines developed by the steering committee will be evaluated and scored on a 9-point Likert scale by the PDG members. Items with a score of seven and above by more than 70% of PDG members will be included in the second draft of the guidelines, and the Delphi process will be repeated until each item fulfils the set conditions. After obtaining consensus from the PDG, the PRIRATE guidelines will be discussed by 20 selected individuals within a PRIRATE Face-to-face Consensus Meeting Group (PFCMG) to arrive at a final consensus. The final PRIRATE guidelines will be accompanied with an explanation and elaboration document developed by the steering committee and approved by six members, three from the PDG and three from the PFCMG. The PRIRATE guidelines will be published in journals and actively disseminated to educational institutions, national and international academic societies and presented at scientific meetings. The steering committee will periodically revise and update the PRIRATE guidelines based on feedback from stakeholders.