Thomas Kvist
Associate professor, DDS, ph.d. Department of Endodontology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
Bjørn Hofmann
Professor, ph.d. Department for the Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway and Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway.
Joséphine Brodén
DDS, ph.d. Department of Oral Biology, Faculty of Odontology, Malmö University, Malmö, Sweden.
Leo Tjäderhane
Professor, DDS, ph.d. Department of Oral and Maxillofacial Diseases, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland and Research Unit of Oral Health Sciences, and Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland.
Headline
This paper is concerned with uncertainties and decision making in endodontics. Uncertainties are of different kinds; risk, fundamental uncertainty, ignorance and indeterminacy. The various types of uncertainties that are involved in the process of clinical making decisions are briefly reviewed in case of an injured vital pulp, a necrotic pulp with apical periodontitis and finally a root-filled tooth with a persistent apical lesion.
Professional judgments in endodontics as in any medical discipline must be based on qualified estimations of the probability and value of relevant outcomes. In this paper, we briefly discuss how attention to various types of uncertainties are involved in the most common endodontic decision-making situations.
Uncertainty
There are many kinds of uncertainties that are relevant to decision-making in endodontics First there are situations where the outcomes are well known, and we know the probability distributions of these outcomes. That is, we know what might happen, and we know the probability that it will happen. For example, we know that some vital teeth will become necrotic following crown preparation and we know its probability distribution. This is frequently referred to as risk. However, oftentimes we know the outcomes, i.e. what might happen, but we do not know the probability distributions. This is called fundamental uncertainty. This, of course, makes it more difficult to make decisions, and we try to reduce fundamental uncertainty to risk by expanding evidence. However, we may also encounter situations where we do not know the outcomes. That is, unexpected things may happen. This is called ignorance in philosophy of science as in ordinary language. For good and bad, we need to be aware of such unexpected outcomes. As with the discovery of X-rays, unexpected consequences can be beneficial. However, they can also be detrimental. One additional kind of uncertainty is not related to knowledge of outcomes and their probability distributions. It is related to how we define things. Pulpitis can be defined and classified in different ways, and presence of apical periodontitis, particularly in connection with root filled teeth, can be determined in a variety of ways. Which definitions and measures we apply may depend on what we want to obtain, i.e. our social commitments. This type of uncertainty is frequently called indeterminacy. Hence, when we make decisions, it is crucial that we base them on evidence that applies definitions and measures that are relevant to the specific case that we are treating. In sum, we face with four types of uncertainty that are relevant for decision-making: risk, fundamentaluncertainty, ignorance, and indeterminacy.
Decision making
When practicing, the dentist constantly makes a lot of decisions of various kinds. The term clinical decision making usually refers to the management of three fundamental questions. What is the problem?, What are the possible solutions? and What is the best solution for this patient Clinical decision-making can be examined from both a descriptive and normative approach. Descriptive projects aim at mapping out and explaining clinicians' reasoning and how they make decisions. Normative projects, on the other hand, are involved with how decisions should or ought to be made.
Descriptive decision making
Several models have been suggested to describe how clinicians make decisions []. Some investigators have concentrated on the artistic, or intuitive, aspects of clinical practice Using judgement analysis researchers have tried to reveal the pieces of information or cues, used at conscious or unconscious levels, that effect a person's decision-making []. In a series of investigations Tversky & Kahneman explored the idea that people most often rely on a small number of heuristic principles to make decisions. Their important empiric supported insights into human thinking have been summarized in an easy-to-read bestseller [].
Normative decision making
There is no general agreement of the right way to make decisions clinical decisions. Dentistry, like medicine, is an applied science. Since each patient is unique and have distinctive preferences, it can be tricky to decide how to apply the science and evidence to each individual situation. Each clinician compiles their own data and constructs an argument based on their interpretation of facts. The strength of their case will depend on the way they collect and interpret information []. The patient's participation in the process is central. Autonomy, or self-determination, means that an individual has the right to decide on matters regarding his/her own body, mind and life. The right to autonomy has a strong foundation in diverse ethical theories [] and includes a person's right to decide on his/her health care. To be able to make an autonomous decision, the dentist consequently must to the best of his/ her ability provide the patient with all relevant facts; the findings, the etiology of the disorder, the various possible options to deal with the situation, risks, and probable long-term outcome with or without any treatment. The clinician must also be able to discern the essential circ
