Arshad Hasan*, Yawar Ali Abidi**, Mariam Iqbal***, Farhan Raza Khan****, Haji Sohail*****
- Assistant Professor & Head Dept of Operative Dentistry, Hamdard University Dental College.
- Assistant Professor, Dept of Operative Dentistry, Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences. Karachi.
- Assistant Professor, Dept of Operative Dentistry, Jinnah Medical & Dental College. Karachi
- ****Senior Instructor, Dept of Operative Dentistry, Aga Khan University Hospital. Karachi.
- *****Final Year BDS Student, Hamdard University Dental Hospital. Karachi.
Correspondence: “Dr. Arshad Hasan” <email@example.com>
How to CITE:
J Pak Dent Assoc 2010;19(3): 144 -147
Dental caries and its sequel pulpitis, is one of the most common complaint with which the patient attends a dental office. The diagnosis of pulpitis involves distinguishing the two types, i.e.; the reversible and irreversible pulpitis, through objective and subjective testing. This process is usually straightforward but can at times be difficult due to anatomical, physiological and psychological factors. The Purpose of this questionnaire based survey was to find out the ability of dentists in diagnosing irreversible pulpitis.
The study design was cross sectional. Two hundred single clinical scenario based questionnaires were distributed among 3 dental colleges. Totally 142 questionnaires were received back. Respondents were the clinical staff (consultants, senior registrar, residents, demonstrator, house officers and final year students) of the 3 dental colleges. The respondents were asked to diagnose the clinical scenario as either reversible or irreversible pulpitis
Most of the participants (81.7%) gave a wrong diagnosis. Worst response was from the final year student category (88.6%) whereas best response was in the resident category (44.4%). The difference was statistically significant (p<0.05).
The ability of participants in diagnosing the clinical scenario correctly was poor in all categories.
Irreversible pulpitis, carious lesion, diagnosis, lingering pain.
Diagnosis may be termed as one of the most important factors which dictate the treatment and the successful outcome of the care., Treatment rendered without correct diagnosis can lead to under or over treatment. In endodontics, such treatment can result in treating a wrong tooth or wrong treatment on a diseased tooth. Patient may continue to have pain and the situation
will be embarrassing for the care provider. Most common endodontic etiology is either pulpitis or periapical pathosis. Out of them, pulpitis can present with diagnostic difficulties for the unwary.2 With different treatment regime for reversible and irreversible pulpitis, it is important to diagnose each condition with absolute surety and treatment rendered in the best interests of the patient. Patient’s best interests are served only if a procedure can guarantee pain free function for an extended period of time, perhaps for the lifetime of the patient.
Lingering of pain is one of the criteria used to distinguish between reversible and irreversible pulpitis. There is a unanimous agreement in endodontic literature that if there is lingering of pain for more than a few seconds duration, the diagnosis invariably is irreversible pulpitis. ,, The purpose of this study was to test the hypothesis that the ability of dentists, working in academic institutions of Karachi, is poor in diagnosing pulpitis.
The current study was Cross sectional in design, carried out at the Hamdard University Dental Hospital, Fatima Jinnah Dental College and Jinnah Medical and Dental College, Karachi. It involved a self administered, single clinical scenario based questionnaire.
The respondents were the clinical staff of above mentioned institutions in following categories; consultant, senior registrar, resident, demonstrator, house officer and final year student. The questionnaire used in the study is shown in figure no. 1. The data collected from the filled questionnaire was analyzed using S.P.S.S. version 15.0 for Windows. Chi Square test was used to see the difference in proportion of dentists diagnosing the case correctly
Kindly go through the following scenario and give your opinion.
Dear Sir / Madam,
Department of Operative Dentistry, Hamdard University Dental Hospital would like your participation in a questionnaire based study. Kindly fill out the following information.
What describes you best?
- Final year student
- House officer
- Senior Registrar
A 35 years old male patient presents with pain and sensitivity in his left maxillary first molar. The symptoms appear on taking cold and remain for 5 minutes. The radiograph shows a deep carious lesion and no periapical pathology. Tooth is not tender to percussion. The patient is suffering from
A- Reversible Pulpitis
B- Irreversible Pulpitis
A total of 200 questionnaires were distributed out. One forty two (142) were received back which resulted in a response rate of 71%. Out of 142, 19 (13.4%) respondents belonged to consultant category, 3 (2.1%) senior registrar, 9 (6.3%) residents, 26 (18.3%) demonstrators, 40 (28.2%) house officers and 44 (31%) to the student category. A total of 26 (18.3%) respondents chose irreversible pulpitis as their final diagnosis, whereas 116 (81.7%) diagnosed it as reversible pulpitis
This difference was statistically significant (p < 0.05). Within the faculty, the breakdown of responses (table no 1) varied considerably. Biggest difference was seen between the resident group (44.4% answered irreversible pulpitis) and the student group (11.4% answered irreversible pulpitis). This difference was statistically significant. (p<0.05).
Diagnosis of pulpitis depends on accurate reproduction of patient symptoms and its correct interpretation by the clinician. Lingering of pain is one of the main features of irreversible pulpitis that helps in its diagnosis. Various authors have described this lingering nature accordingly. Cohen and Burns have defined irreversible pulpitis as a lingering pain that is provoked or unprovoked, which does not subside almost immediately.5 Guttmann and Dumsha define it as pain that lasts for more than 15 seconds6. Roberson and Heymann describe it as pain produced by thermal stimuli that continues for more than 10 seconds after termination of stimulus. 7 According to these descriptions, the correct answer of our clinical scenario is option B, i.e irreversible pulpitis.
However, majority of respondents (81.7%) chose option A, i.e. reversible pulpitis. The reasons for such a high percentage of wrong diagnosis could be multiple. Lack of carious exposure of pulp on radiograph could be one reason. The radiographic appearance of a carious lesion is not a true representative of the actual depth of carious lesion.,,, The carious lesion may have invaded pulp but may not be evident radiographically as a radioleucency requires a certain amount of demineralization before becoming radiographically detectable. Other reason for incorrect diagnosis could be the lack of periapical changes. Periapical changes are evident only after pulpal inflammation has spread there. As a result, irreversible pulpitis may not have any periapical changes in initial stages.5 Another reason could be the appearance of symptoms to cold. Current thinking on thermal stimulus and its relationship to pulpitis is that it is not the type of stimulus rather it is the character, lingering nature and spontaneity of pain that determines the diagnosis.1,3,,
Highest percentage of incorrect diagnosis (88.6%) was made by the students. This was probably because of the fact that their understanding of disease process was not at par with other categories. Highest percentage of correct diagnosis (44.4%) was made by the residents. The reason could be their better understanding and continuous updating of their knowledge.
This survey highlights another important issue. If the treatment is delayed on a tooth with symptoms of irreversible pulpitis, the pulp space may not only become sclerotic, making endodontic therapy difficult, necrosis and eventual apical periodontitis will cause a substantial decrease in success rate.1 These interpretations were established by recently conducted Toronto study. The researchers concluded in the phase 1 of the study that the success rate of endodontic procedures on teeth without apical periodontitis(92%) was superior to the ones that exhibited such lesions(74%). The results were confirmed in phase 4 of the above mentioned study. The same results were re-confirmed when the cohorts were followed upto
10 years. A small sample size and lack of a radiograph in the questionnaire are the two limitations of this study.
We were unable to find a similar study published in dental journals
Following conclusions can be drawn from this study
The ability of the study participants in diagnosing the irreversible pulpitis in the given clinical scenario was poor.
Endodontic treatment on teeth with irreversible pulpitis should not be delayed, as it will substantially reduce the success rate.
The performance of students indicates a need for proper training in diagnosing pulpitis.
A relatively better performance by the residents indicates a need for regular continuing education programs for all members of faculty.
Similar questionnaire based studies are needed to identify other areas of weakness
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