Dentaltown January 2015 - (Page 84)

Endodontics feature DIAGNOSIS IN ENDODONTICS by Scott Weed, DDS EVERY DECISION WE MAKE IN CLINICAL DENTISTRY INVOLVES SOME DEGREE OF UNCERTAINTY WHETHER WE RECOGNIZE IT OR NOT. MOST PATIENTS DON'T APPRECIATE THE UNCERTAINTY WE FACE AND OFTEN DEMAND DOCTORS WHO ARE CONFIDENT AND CERTAIN, WHO ALWAYS HAVE THE CORRECT ANSWERS. It is important to understand that many errors in judgment are a result of our human thinking processes-processes that are common to all rational beings. We must also recognize and embrace the inevitable uncertainties in clinical decision-making by applying principles of probability in ways most of us were never exposed to in school. Finally, we need to understand the nature of endodontic diseases and why our endodontic tests often fail us. Part 1: Judgment under uncertainty In the early seventies, many of the weaknesses of the human machinery used for making judgments in the face of uncertainty were delineated by Amos Tversky and Daniel Kahneman. They explained that people tend to utilize "heuristics," which are rules of thumb, and these heuristics can lead us to biased decisions. Heuristics are built-in, experience-based shortcuts we all rely upon to quickly process information. However, because heuristics are so commonly used (subconsciously), they easily convince our brain that the conclusions they point us towards are automatically valid, and this is certainly not true. Some well-known heuristics have been described in the cognitive science literature: Anchoring Heuristic For example, a patient reports of pain on the upper right with tooth #3 displaying a large area of coronal destruction due to caries may in uence how we interpret a periapical radiograph of . s a specialist, I often get referrals where the patient or referral slip reports a periapical radiolucency ("my dentist says there's a 'dark spot' on the X-ray") when none of my 2D or 3D images corroborate this. In these cases, the clinician probably allowed early information to "anchor" his/her thought process, leading to the overly concrete and speciﬁc visuali ation of a radiolucency on the imaging. This is especially problematic for younger and less experienced clinicians. When I was in my residency, I would frequently discuss cases with undergraduate dental students who would tend to "see" radiolucencies on periapical radiography when I could appreciate no such radiographic feature. By way of clinical advice, on cases where you suspect subtle radiographic perturbations, scan other areas of the image and see if similar areas don't show up on adjacent teeth. Availability Heuristic We should be careful when we are interpreting the subjective and objective information we've collected from patients and at least recognize the availability heuristic. For example, pain on a tooth with recent restorative work very well could be pain of endodontic origin that requires endodontic therapy. However, in my practice, occlusion and overall life stress of the patient are large factors that I always consider, despite the very plausible explanation of pulp trauma from dental treatment. Failure to include other hypotheses in the diagnostic work-up generally leads to people getting root canals they didn't need. Representativeness Heuristic A good example of this is the terrible-looking root canal treatment. ften we see short root ﬁ lls, missed canals, weak or incomplete ﬁ lls and we infer disease from these features even in the absence of clear clinical ﬁ ndings or patient reports of symptoms. Combined with anchoring, we might even infer a periapical radiolucency on the image when in fact none exists. I had a patient referred to me one year ago with complaint of pain on #9. Her dentist had recently performed root canal therapy on that tooth. When I examined her, it was clear her problems continued on page 86 84 JANUARY 2015 » dentaltown.com http://www.dentaltown.com

Table of Contents for the Digital Edition of Dentaltown January 2015

Dentaltown.com Highlights
Howard Speaks: Why Too Much Clinical Dentistry is Bad for Business
Professional Courtesy: Coming Soon: More Denture Patients
Continuing Education
Sleep Apnea Screening and Treatment
Data Encryption: Count the Acronyms
Anterior Tooth Position in Restorative Dentistry: Applying the Chasolen Triad
Poll
Office Visit: Texas Hygienist a Diva of Dings
What is the Current Science Behind Socket Grafting to Preserve Ridge Height?
Pulp Capping: Improving the Prognosis
Industry News
New Products
Should I Extract That Tooth?
Townie Meeting 2015 Preview
Ad Index
Remembering Suzanne Mann
Diagnosis in Endodontics
Quickbooks: Ten Tips to Stay Organized and Efficient
Dentally Incorrect

Dentaltown January 2015