Endodontic clinical diagnostic, investigatory skills, and decision-making capabilities in treatment strategies among undergraduate students

INTRODUCTION

Every dentist’s primary goal is to treat any pathological oral cavity condition appropriately. In dentistry, achieving this goal is contingent upon performing an accurate diagnostic evaluation and meticulous clinical (oral) examination.^[1] This is particularly crucial in endodontics, where routine chair-side diagnostic procedures and investigatory findings, such as laboratory and radiological investigations, help choose the most suitable treatment options, thereby minimizing or even eliminating postoperative discomfort, the most common undesirable experience for the patient.^[2]

Pain is the driving factor for patients to visit an endodontist. The cause of the tooth pain is mainly related to pulp and periapical pathology. Various factors, such as collateral blood supply, referred pain, and non-odontogenic pain, make the exact location of pulpal pain more critical for the clinician and patient.^[3] Hence, diagnosing such pathology includes several sequential steps, such as a chief complaint, medical and dental history, and clinical examination, followed by diagnostic and radiological examinations.^[3] If the diagnostic tests are inconsistent with the chief complaint, it will be challenging for a dentist.^[4]

The clinician must have adequate, updated knowledge and efficient clinical reasoning to reduce the possibility of false-positive or false-negative errors and arrive at an evidence-based best clinical diagnosis.^[4,5] Efficient guiding and extensive training of dental students are needed in diagnostic procedures and clinical examination processes. They also must be taught by supervising staff members to develop clinical skills to differentiate pulpal periapical pathology in symptomatic and asymptomatic teeth.^[6]

It is of paramount importance for undergraduate students to acquire proficient endodontic diagnostic skills throughout their Bachelor of Dental Surgery (BDS) course. This necessitates rigorous training under competent supervision, which enables students to progressively enhance their knowledge from the 3^rd to the 4^th year of the internship. The clinical training equips students with the competence to make precise diagnoses and devise various treatment options in endodontics. The study, which aimed to assess these skills in undergraduate students, has the potential to significantly influence the future of dental education and practice. The results of this study serve as a catalyst, inspiring and motivating the dental community to enhance their diagnostic skills and contribute to improving patient care in the field of endodontics.

MATERIAL AND METHODS

The current research was a descriptive, cross-sectional, questionnaire-based online study that has been selected and approved. It was awarded the Undergraduate Students Research Scholarship program (UGSRS) 2023 by DR YS Rajasekhara University of Health Sciences, Vijayawada, Andhra Pradesh. The study included undergraduate dental students in their 3^rd and 4^th years and an internship for a BDS course at Narayana Dental College and Hospital. The study was started after receiving ethical approval from the Institutional Ethical Committee (IEC) with the reference protocol number IEC/NDCH/2023/AUG-SEPT/P-55.

The students were divided into three groups based on their year of BDS.

• Group A – 3^rd BDS

• Group B – 4^th BDS

• Group C – Interns.

The questionnaire, a pivotal tool in our study, was designed to comprise ten multiple-choice questions. The first three questions were aimed at recording general information about endodontic diagnosis procedures. The subsequent six questions presented hypothetical clinical case scenarios. The remaining two questions featured pictorial representations, where participants were asked to state their diagnosis, identify the need for further special investigations if needed, and provide treatment options. All questions were in a multiple-choice format, with some questions allowing participants to write another diagnosis, condition, or procedure that was not listed or even combine the options.

The principal researcher (SK Chashma) and the administrator support (Dr. G. Kiranmayi), who are experienced dental educators and researchers, emailed the online questionnaire to all three groups included in the study. Their expertise in the field of dentistry ensures the credibility and reliability of the research. They also informed all participants about the research study by sending an invitation email and including them based on their volunteer. Informed consent was obtained from students in the first part of the online survey.

The online survey was made available to all participants on September 30, 2023, and was closed on October 30, 2023, providing a month for participants to respond. Email reminders were sent to encourage participation and boost the response rate. After collecting all the responses from the volunteers, the data were meticulously collected, retrieved, and tabulated for descriptive analysis. A comparison was drawn between the different levels of undergraduate dental students from years 3, 4, and internship.

The percentages were used to describe frequencies and were represented in tables for interpretation. The levels of undergraduate dental students from years 3 and 4 and BDS interns were compared. The data were analyzed descriptively, as many of the correct answers for the given questions’ dependent variables are multiple, with three or four options.

In this study, 228 students at Narayana Dental College and Hospital replied to the questionnaire with a response rate of 73.5%. Overall, 23% of the participants were male. Around 69 (84%) students from the 3^rd year, 68 (84%) students from the ^4th year, and 86 (86%) students from the internship participated in the study. The questions from 4 to 11 were related to different clinical/case scenarios hence they were framed based on diagnosis and treatment options to those discussed.

The first three questions were based on the basics of endodontic diagnosis and were given to the students to enhance their confidence levels. It was found that more than 76% of the interns, 53% in their final year, and 56% of 3^rd-year BDS students responded that electric pulp sensitivity tests were needed to evaluate pulp vitality. Around 66% of the 3^rd year, 77.6% of the final year, and 72.9% of interns considered that pulpal necrosis shows delayed or no response to electric pulp testing. 66.7% of 3^rd-year students, 100% of final-year students, and 91.9% of interns considered that Ellis the questions from 4 to 11 were related to different clinical/case scenarios hence they were framed based on diagnosis and treatment options to those discussed.

RESULTS

According to the question as shown in Table 1 the correct response for the diagnosis was a chronic periapical abscess. Around 58.7% of the respondents in Group A, 59.7% in Group B, and 77.9% in Group C marked chronic periapical abscess as the correct answer. In contrast, pulpal necrosis was selected by 17% of the respondents in Group A and 15% in Group C. In the second part of the question, it was found that students in Group A - 32% answered radiological examination, 29% chose electric pulp tests, and 23% selected thermal pulp testing. 52% of Group B selected electric pulp testing and GP sinus tract tracing, and 29% selected electric pulp tests as relevant tests. Group C 50% chose both thermal tests and GP tracing, and 23% selected electric pulp testing and GP sinus tract tracing. Regarding thermal pulp tests, the response rate was much higher in the Group A (47%) and Group B (57%) groups, and for the electric pulp test, it was higher in the Groups A and B (71%) groups.

The answers to the condition with a pinpoint exposure of the pulp were either reversible pulpitis or pulpal exposure of the tooth as shown in Table 2. Pulpal exposure was selected as the highest option in all groups, with 53.7% and 59.3% for Group B and Group C, respectively. In contrast, 53.3% of Group A did not answer the question or selected none as the answer. The second part of the question asked for an accurate diagnostic test. Again, most participants in all three groups selected the IOPA radiograph option, with a response rate of 65.3% in Group A, 47.8% in Group B, and 73.3% in Group C groups. 10% of Group A and 25% of Group B selected both EPT and IOPA as diagnostic tests. 70.7% of Group A, 77.6% of Group B, and 62.8% of Group C participants had chosen direct pulp capping as a treatment option to manage pulpal exposure.

According to case given in Table 3, 79.3%, 100%, and 89.5% of students from Groups A, B, and C selected the Avulsion as the correct answer; 41.3% of students in Group A, 90.7% of students in Group C chose radiographic examination, and 40.3% of students in Group B selected both vitality tests and radiographic examination as relevant investigations tests. Regarding the treatment plan for this clinical scenario, 78.7% of students in Group A chose the most realistic answer, reimplantation. 58.3% of Group B selected Re-implantation along with splinting, and 41.9% of students in Group C selected re-implantation, root canal treatment (RCT), and splinting as the choice of treatment methods.

According to case as shown in Table 4 100%, 89.6%, and 90.7% of students from Groups A, B, and C selected acute irreversible pulpitis as the correct answer. Among Group A, 52% selected thermal tests, EPT, IOPA, and percussion tests, and 18.7% selected thermal tests and IOPA as relevant tests. 41.8% of students from Group B selected thermal along with IOPA, EPT, and IOPA. In Group C, 38.4% selected thermal, IOPA, and percussion tests, and 17.4% selected EPT, IOPA, and percussion tests. Regarding the treatment plan for this clinical scenario, 84.8% of students in Group A, 92.5% of Group B, and 88.4% of Group C selected the RCT as the correct answer.

According to case shown in Table 5 56%, 71.6%, and 82.6% of students from Groups A, B, and C selected the correct answer: Reversible Pulpitis with Normal Apical Tissue. 38.7% and 64.2% of Groups A and B selected IOPA, 37.2% selected thermal tests EPT along with IOPA, and 24.4% of Group C selected EPT and IOPA as relevant investigation methods. Regarding the treatment plan for this clinical scenario, 77.3%, 64.2%, and 86.0% of students in Groups A, B, and C chose the most acceptable answer: Permanent restoration. It was followed by 35.8% of students in Group B and 17.8% in Group A who chose RCT.

The correct answer to the possible causes of tooth discoloration was dental fluorosis shown in Table 6. It was selected as the highest option in all groups, with 72%, 100%, and 92.7% for Groups A, B, and C, respectively. In contrast, dental sclerosis was selected by 14% in Group A and 8% in Group C. The second part of the question asked for a relevant diagnostic test. Again, most participants in all three groups selected none of the needed vitality or radiographic tests, with a response rate of 64.8% in Group A, 88% in B, and 90.7% in C. The third part of the question asked how to manage tooth discoloration. Most participants in all three groups selected the bleaching option, with a response rate of 80% in A, 92.5% in B, and 90.7% in C groups.

Identify the procedure

According to given case scenario 10, as shown in Figure 1, represents the apexification procedure. Many students from the Group B (95.5%) and C (88.4%) groups chose Apexification. Approximately 93.8% of Group A students submitted options other than apexification.

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Figure 1:

Representing (a) tooth with open Apex and (b) tooth after MTA apexification (arrow represents the open apex in a).

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According to case scenario 11, as shown in Figure 2, the correct answer for recognizing the procedure in the Figure 1, the correct answer was indirect pulp capping, selected by 53.8% of students in Groups B, 86% in C and only 12% in the Group A. The others from Group C mentioned cavity preparation. Regarding the participants’ selection of the correct option to detect, the three materials shown in the picture were as follows: for material 1, 56.7% of group A and 76.7% of the C group selected permanent restorative material. 73.3% of Group A selected fissure sealant. For material 2, 76.0% of Group A, 56.7% of Group B, and 76.7% of Group C were chosen as base material. For material 3, 76.0% of Group A, 56.7% of Group B, and 75.6% of Group C were selected as sub-base or pulp capping agents.

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Figure 2:

Representing (a) tooth with deep caries lesion, (b) after caries excavation, (c) application of liner, base and restoration. 1-Restoration, 2-Base, 3-Liner

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DISCUSSION

BDS at Narayana Dental College and Hospital is an undergraduate course with a 5-year academic curriculum program. To complete this curriculum, students must learn the theory that helps them compete, have thorough clinical knowledge, and possess self-motivation to develop interpersonal skills.^[7,8] As many critical aspects are included, from the diagnosis to obturation, followed by permanent restoration, endodontic treatment may be stressful for undergraduate students.^[9].Meanwhile, the procedure performed most in clinical practice needs proficient technical abilities, experience, and knowledge of pulp, root canal anatomy, and its variants.^[10] As a result, undergraduate students need to have high self-confidence in their theoretical knowledge and clinical abilities in endodontics. Undergraduate students’ self-evaluation would be valuable for objectively analyzing the dental curriculum and determining the most beneficial courses.^[11] Rather than giving only theory-based questions, it is more helpful to present hypothetical clinical conditions for the students where they should conclude the diagnosis, plan the investigatory tests, and decide the treatment options.^[12] The students were split up by their academic years to see if there were any differences in their learning and understanding abilities.^[13]

Generally, students have less knowledge regarding diagnostic skills and treatment plans than experts in the endodontic fields.^[14] Interns who had finished dental undergraduate courses were expected to have enough theoretical and practical knowledge.^[15] Thorough knowledge of clinical findings and necessary investigation methods for pulpal or periapical pathology leads to accurate diagnosis and treatment.^[16] Knowledge-based clinical scenarios or situations are required to enhance diagnostic skills and decide treatment options.^[17] It will help the students in facing such clinical conditions. Hence, the study used a clinical scenario and a pictorial representation of treatment methods in the questionnaire.^[18] A lack of diagnostic skills, such as correctly interpreting an X-ray and drawing conclusions from the pulp sensibility tests, was a significant cause of diagnostic errors.^[19]

In this study, the total response rate of students was 73.5%. The response rate is a crucial factor in the reliability and validity of the study’s findings. While the literature does not specify a minimum response rate, some authors suggest that a 70–80% response rate is sufficient to rule out nonresponse bias.^[20] Therefore, a response rate of 70% is considered adequate for questionnaires targeted toward undergraduate students. The response rates from all 3 years may vary due to factors such as the type of questions asked, number of students per year, year of study, duration of clinical exposure, and offline/online mode of approach of the questionnaire. The current study’s response rate was more than acceptable, even with the participants being reminded through email every 2 weeks since the survey was opened. The principal investigator guide of the study gave reminders by approaching the undergraduate dental students during their lectures, practicals, or clinical sessions. In addition, representatives from each group were sent an email asking them to get their colleagues to participate in this study. Although the method was time-consuming, the effect was noticeable, as the response rate increased to 75.3% when the survey was closed.

In making an accurate diagnosis, the patient’s subjective symptoms must be recorded carefully, and the symptoms should be correlated with objective clinical pulp sensibility tests. Pulp diagnosis typically entails a thermal or electrical sensitivity test, which aims to excite the pulp by causing a fluid flow in the dentinal tubules.^[21] The study results revealed that most undergraduate dental students of all 3 years were unaware of the pulp sensibility tests diagnostic tools. However, it was reassuring to notice that the 3^rd- and 4^th-year students were more aware of the importance of diagnostic tests being preferred during various clinical conditions compared with interns. This awareness is a positive sign of the student’s understanding of the importance of diagnostic tests in their future practice.

In answering most clinical scenario questions, 3^rd-year students from Group A chose the correct answer less frequently than Groups B and C. For example, in the second clinical scenario of Group A participants, a few students (29.3%) were considered compared to 57.3% and 59.3% of Group B and C participants, respectively. 3^rd-year students still had to improve their capabilities by correlating theoretical knowledge with clinical scenarios. The possible reasons could be attributed to the different learning modes of the students, such as visual, auditory, and kinesthetic reading and writing. Students’ abilities to recall information gathered from listening to teachers and reading books are similar. Students answered only some of the questions, and the reason for this may be attributed to a lack of knowledge, response bias, and a lack of desire to answer the questions.^[22] Many undergraduate dental students reported having trouble with endodontic diagnosis in a clinical environment comprising diagnostic tests and differential diagnosis. According to the study results, many interns needed to consider themselves knowledgeable in endodontic diagnosis. According to the feedback, undergraduate students felt incompetent due to insufficient clinical experience.

In the second clinical scenario, many Group A participants chose Avulsion to answer the knock-out of the anterior tooth in a 13-year-old boy (73.3%). The students who chose the same option increased in Groups B and C by 100% and 89.5%, showing a high level of knowledge and preparedness regarding traumatic injuries. The same observation was noticed in the third hypothetical clinical case scenario, as 100% of Group A, 89.6% of Group B, and 90.6% of Group C selected the correct diagnosis regarding acute irreversible pulpitis, respectively. This level of knowledge and preparedness is a testament to the students’ understanding of real-life clinical scenarios. The same result can be observed when participants are asked about the clinical tests or examinations they want to perform before making a definitive diagnosis and managing an avulsed tooth. The participants were provided options for vitality tests, periapical radiographs, re-implantation, and splinting RCT.

Many Group A participants would consider vitality tests, radiographs, and re-implantation splinting options before making a definitive diagnosis and treatment plan. Groups B and C had the highest percentage of participants who selected vitality tests, radiographs, re-implantation, and RCT splinting as correct possibilities before making a definitive diagnosis, followed by interns and the 3^rd year. A possible explanation could be that there was less exposure to clinical cases of Group A compared to the rest of the groups. The study assessed the impact of early endodontic-related clinical exposure on undergraduate dental students’ learning experience.^[23] The study used questions on clinical scenarios and pictorial representation of clinical methods. The study also included interactions with all the dental students and their concerned staff members. Their response concluded that early clinical exposure was helpful because it gave students a context for their theoretical learning, helped them learn how to apply their knowledge in clinical practice, and improved their interpersonal skills and ability to work as a team.^[24] All three groups of students selected correct answers for the first three basic questions of endodontic diagnosis. Surprisingly, it was noticeable that Groups A and B participants were more aware of the clinical condition diagnosis than Group C participants. The possible explanation could be attributed to the different learning abilities of students in additional years.^[25] The findings obtained from clinical examination and radiological investigations were crucial to making an accurate diagnosis and treatment plan. It is necessary not only to identify the clinical condition but also to draw the confirmation of the pathology using vitality tests and radiographs.

Hence, students must collect information from clinical examinations and diagnostic tests to plan treatment. Regarding various clinical scenarios, the study showed that the 3^rd-year undergraduate students chose the correct diagnosis less frequently than the 4^th-year and intern students, and the reason may be that they were less exposed to clinical cases than other groups.

A lack of knowledge is the reason for diagnostic failure only rarely.^[25] In contrast, few studies have mentioned that insufficient knowledge can lead to improper diagnosis, which can cause premature closure even in experts.^[21] Early introduction to clinical exposure might enhance the undergraduate student’s learning abilities, as proved in previous studies. It concluded that the students and supervisors perceived early clinical exposure to help offer a context to students’ theoretical learning and develop their understanding of applying knowledge, interpersonal skills, and teamwork skills in clinical practice.^[25] In this study, the percentage of students who chose the correct diagnosis increased from the 4^th year to interns. However, only a high rate of intern students could identify the proper treatment plan for a particular diagnosis. The result can be attributed to the different abilities of students to recall information, lack of knowledge, or response bias, which means a lack of desire to answer the questions.

According to De Moor et al.,^[24] the curriculum should include elements of instructional teaching, pre-clinical operative technique classes, and clinical patient treatment; clinical endodontics should preferably be supervised by specialists or staff members with enhanced knowledge and well-versed skills in performing endodontic treatment; assessing the clinical application knowledge by various approaches such as online, offline methods, interaction with patients in educating motivating them and getting feedback from the student’s procedures should be an include in the curriculum in endodontics. There are several limitations to this study. The result only represents some dental colleges, as the research has been done only at one. The study’s response rate (75.3%) was reasonable. Finally, the current study’s questionnaire was designed with multiple correct options for most questions. It is challenging to compare the overall answers from the three student groups; hence, a descriptive analysis was chosen for the study. There may be observer and respondent bias regarding the actual response.

CONCLUSION

Newly passed-out undergraduates are considered to have excellent theoretical knowledge and have received teaching to improve their ability to face any clinical condition and communicate with patients in an empathic way. Students must have enough basic clinical skills to practice confidently and give patients high-quality treatment. However, students feel less confident when treating complicated cases due to needing more skills. Changes in teaching methods, adequate teaching faculty, improved staff/student ratios, and the adoption of outreach teaching centers are potential solutions to increase clinical experience and authenticity. Finding the learning modes of students and planning the teaching methods according to those methods will provide adequate teaching and learning.

The 3^rd-year undergraduate students presented with fewer clinical skills than 4^th-year and intern students because of lesser clinical exposure. Furthermore, students must be updated with current practical skills and knowledge in addition to the information in the textbook. The most important factor defining the accuracy of endodontic diagnosis is clinical training. The quality of dental education will develop when dental students have improved diagnostic skills and can choose accurate treatment options.

Future research is needed to find various methods to improve, enhance, and educate the students from the 3^rd year through the final year of the internship.