ORIGINAL ARTICLES DERIVED FROM RESEARCH

GUIDELINES FOR CLINICAL DIAGNOSIS OF PULP AND PERIAPICAL PATHOLOGIES. ADAPTED AND UPDATED FROM THE "CONSENSUS CONFERENCE RECOMMENDED DIAGNOSTIC TERMINOLOGY" PUBLISHED BY THE AMERICAN ASSOCIATION OF ENDODONTISTS (2009)

Talía Y. Marroquín Peñaloza¹; Claudia C. García Guerrero²

¹ DDM, Endodontics Specialist, Universidad Nacional de Colombia
² DDM, Endodontics Specialist, Pontificia Universidad Javeriana. Assistant Professor, Universidad Nacional de Colombia. E-mail: ccgarciag@unal.edu.co

SUBMITTED: APRIL 9/2013-ACCEPTED: NOVEMBER 10/2013

ABSTRACT.

INTRODUCTION: accurate diagnosis in endodontics leads to the selection of adequate endodontic treatment. The terms used to name each pathology must be associated to particular clinical conditions. The standardization of diagnostic terminology in endodontics has been widely discussed in the academic and clinical fields. The objective of this study was to adapt and update the Guidelines for clinical diagnosis of pulp and periapical pathologies under the parameters of the ADAPTE methodology for circulation and socialization within the academic and professional communities.
METHODS: guidelines search was conducted in compiling agencies such as the National Guideline Clearinghouse (NGC), USA National Center of Guidelines, and the Agency for Healthcare Research and Quality (AHRQ). Guidelines were selected with the AGREE II tool, considering AAE's document "Consensus Conference Recommended Diagnostic Terminology" (2009) as "recommendable", and initiating the adaptation process with ADAPTE. The source databases include Cochrane, PubMed, Tripdatabase, with verifiable key words in DeCS and MeSH. Literature assessment followed the parameters of the Scottish Intercollegiate Guidelines Network (SIGN) and the method of the National Institute for Clinical Excellence (NICE).
RESULTS: adaptation and update of the Guidelines for clinical diagnosis of pulp and periapical disease.
CONCLUSIONS: terminology standardization will allow identifying pulp tissue and periapical conditions. The development of guidelines for clinical practice must be supported on scientific evidence and on agreed methodologies.

Key words: dental pulp diseases, diagnosis, sensitivity and specificity, x-rays, periapical diseases, guidelines for clinical practice as search terms.

INTRODUCTION

Endodontics is a clinical discipline that involves the development of specialized academic activities in microbiology, oral biology, pathology, epidemiology, radiology, and biomaterials, which assist in the diagnosis, prevention, and treatment of pulp and periapical pathologies.¹ Endodontic diagnosis is defined as the process of identifying pulp and periapical conditions, comparing the signs and symptoms of each disease.² However, the terminology of endodontic diagnostic has been a topic of discussion, controversy, and debate for decades.³

The Guidelines for Good Clinical Practice (GCP) and the Guidelines for Clinical Diagnosis (GCD) are recognized as "systematically developed recommendations to help professionals and patients make decisions on appropriate health care, by choosing the adequate diagnostic or therapeutic options in dealing with a health problem or a specific clinical condition".⁴

Since 1990, with the rise of evidence-based medicine, the development of GCP has been implemented to support professional performance in the field of health.^{5, 6}

In Colombia, the Ministry of Health, now Ministry of Social Protection, under Resolution 412 of the year 2000⁷ in accordance with the Agreement 117 of the National Social Security Council, states that "all the activities, procedures, and interventions of induced mandate and enforced observance shall design or adopt technical standards and guidelines of care in order to develop specific protection and early detection actions, along with attention to diseases of interest in public health care."⁷

The same section continues with Chapter I, Article 4, which determines:

Healthcare Guidelines is the document that establishes the activities, procedures, and interventions to be followed in a sequential and logical order for the diagnosis and treatment of diseases of public health interest, established in Agreement 117 of the National Council of Social Security in Health as liability of Health Promoting Entities, Adapted Entities, and Administrators of the Subsidized Regime.⁸

By 2008, program managers of the Workshop of the American Association of Endodontists (AAE)⁹ held the first consensus conference for standardization of diagnostic terminology in endodontics, gathering authorities and experts with the ability to evaluate the best evidence available in this regard.⁹ Aware of this backgrounds, the Endodontics Graduate Program of Universidad Nacional de Colombia School of Dentistry (FOUN for its Spanish initials) proposed to adapt and update the Guidelines for Clinical Diagnosis of Pulp and Periapical Diseases under the parameters of the ADAPTE methodology.¹⁰ This guidelines are intended for the dental profession in general and particularly for clinicians and providers of endodontic services.

METHODS

Initial phase

Topic selection and prioritization of the subject

Confusion in diagnostic definitions increases when clinicians, educators, and researchers use a variety of terms in their teaching and clinical practice to define endodontics diagnosis.^{9, 11} The FOUN Endodontics Graduate Program identified the need to unify the criteria for pulp and periapical disease diagnosis in endodontics (figure 1).

(figure 1)

Formulation of clinical questions for the development of GCD

The objective of this phase was to design clinical questions to develop the topic approached by GCD^{4, 10, 12} (figure 1).

The PICO (patients-intervention-comparisonoutcome) and PIPOH (patient or problemintervention- professionals-outcome-health as context) methods made it possible to formulate wellstructured clinical questions to guide the literature search and the elaboration of recommendations for each endodontic diagnostic.

Adaptation phase

Recognition and application of search engines for diagnostic guidelines

The possibility of consulting other high-quality GCP as secondary sources of scientific evidence can prevent the unnecessary duplication of efforts, especially in the stages of search and evaluation of scientific evidence.^{10, 13}

GCD search included compiling agencies such as:

The National Guideline Clearinghouse (NGC),¹⁴ and the Agency for Healthcare Research and Quality (AHRQ).¹⁵ The Trip Database was also included.¹⁶

Evaluation of the consulted guidelines

The AGREE II assessment instrument (Appraisal of Guidelines for Research and Evaluation II)¹⁷ is known as the most effective tool in the evaluation and validation of the contents of diagnostic and clinical practice guidelines.¹⁸

Inclusion criteria

• Guidelines prepared as part of team activity, based on evidence, with specific, clear recommendations preferably developed by renowned agencies.

• GCP with good quality standards achieving ratings over 60% in each area of the instrument (AGREE II),¹⁷ particularly in the section "Rigor of Development".

• Guidelines developed or updated in the past three years.

• Guidelines developed for implementation in a similar local context, in terms of patients and professionals to whom the guidelines are intended.

Exclusion criteria

• Documents unavailable in Spanish or English.
• Documents whose full version cannot be retrieved.

• Documents which constitute narrative reviews of the literature produced by one or more authors; prevalence, observational or experimental studies.

Guideline selection

Bibliometric description

The process of literature assessment followed the parameters of the Scottish Intercollegiate Guidelines Network (SIGN),^18-21 The strength for recommendation of each study was assessed using the method of National Collaborating Centres and Guideline Developers (NICE),²² which are appropriate for the assessment of diagnostic studies.

As a result, the search yielded a total of 89 items associated to endodontic diagnostic terminology and the applied tests, 32 of which (table 1) were subjected to assessment according to the NICE degree of evidence.²² All the information was finally arranged in templates designed for the evaluation (table 2). Besides the scientific publications, we included relevant archives according to the methodology as well as the official pages for each instrument applied to the entire development of the Guidelines for clinical diagnosis of pulp and periapical diseases (table 3).

DISCUSSION

The need to standardize endodontic diagnostic terminology led to the development of this adaptation/update document of the Guidelines for Clinical Diagnosis of Pulp and Periapical Diseases as a version of the "Consensus Conference Recommended Diagnostic Terminology" published by the AEE (2009). The present document used the ADAPTE methodology¹⁰ as the appropriate instrument for the adaptation process.

The development of a standardized endodontic diagnostic terminology will facilitate communication among scholars, practitioners, and patients,²⁴ favoring accurate decision-making in relation to individual treatment of each pathology.^{35, 53}

Quantification of pulp response to stimuli or diagnostic tests will allow the detection of tissue status. The authors use the term "accuracy" to refer to the amount or frequency in which an applied test correctly classifies a patient.²⁶ The "accuracy" of each test needs to be demonstrated in clinical studies in correlation with Gold Standard tests. Terms such sensitivity, specificity, and predictive values must be closely associated with the clinical interpretation of individual diagnosis.⁵⁴ Extensive revisions and meta-analysis show that current sensitivity tests are subjectively interpreted by both patients and operators, limiting the accuracy of predictive values to assess tests.²⁶

The detection of periapical pathologies of endodontic origin through diagnostic imaging requires some degree of sensitivity in relation to the lesion's extent and its location within the oral cavity.⁵⁴ Two-dimensional images are recognized as tests with high specificity for normal periapical tissue in 100%; however, in the detection of radiolucent lesions the sensitivity of the test may be close to 80%.⁵⁵

3-D cone-beam tomography diagnostic imaging has been introduced in endodontics as a non-invasive tool to diagnose periapical pathologies, known as being 100% sensitive⁵⁶ and considered as the Gold Standard Imaging Test due to its high definition and accuracy.⁵⁷

The development of clinical studies that quantitatively evaluate the application of diagnostic tests becomes increasingly necessary.

CONCLUSIONS

The development of Guidelines for Clinical Diagnosis in Endodontics is an invitation to professionals and scholars to recognize the available methodology for the process of construction or adaptation of GCP based on the contribution of expert consensus, and consolidated through the analysis of clinical evidence mainly, in order to define recommendations as accurate as possible.

ACKNOWLEDGMENTS

The authors thank the group of professors of the FOUN Graduate Program in Endodontics for their recommendations from academia and their perspective as experts in the field.

Similarly, we thank Asociación de Endodoncia de Bogotá for allowing the presentation and socialization of this work.

CONFLICTS OF INTEREST

None of the authors has declared conflicts of interest.

REFERENCES