Pictograph system for diagnosis making and data management in endodontics

Objective: this questionnaire aimed to evaluate the approval of a new pictograph system for endodontic diagnosis by undergraduate and graduate students/ endodontist instead of a conventional method. Methods: after a presentation to a total of 224 participants explaining the pictograph system, the participants (166 undergraduate students and 58 graduate students/endodontist) received a standardized questionnaire with three questions. The data were analyzed using the multprop macro basing on Tukey’s test for multiple comparison with (P ≤ 0.05). The first question was to define the education level of the participants; the second question about which diagnosis method is preferred; and the third question about the intention of using one of the methods in the future. The questionnaire was realized in May 2019. The response rate was 97.7%. Results: the first question showed that 74.10% and 25.90% were undergraduate and graduate students/ endodontist respectively. After statistical analysis there was no significant difference between the groups in the second and the third questions. In the second question (71.08% and 62.06%) of undergraduate and graduate student/endodontists respectively preferred the pictograph method over the conventional method. In the third question (60.24% and 51.72%) of undergraduate and graduate student/endodontists respectively showed interest in using the pictograph method in their professional career. Conclusion: the pictograph method in endodontic diagnosis is accepted by the majority of undergraduate and graduate students/endodontists. Training and experience affect the diagnosis making. RESUMO


O R I G I N A L A R T I C L E
Pictograph system for diagnosis making and data management in endodontics INTRODUCTION T he process to make a diagnosis of a pulp pathology consists of several steps in an established order, producing a series of data reported by clinical examination and radiographical findings [1]. However, this diagnosis is affected by the different professionals' experiences and specialties [2,3]. There is no doubt that the right diagnosis of a pulp pathology leads to the most feasible treatment planning, whether to preserve a tooth or to extract and replace it with an implant among a variety of treatment options [4][5][6].
It is a challenge for both undergraduate and graduate students, as well as for general practitioners and endodontists, to make a decision or a diagnosis [7][8][9][10] due to variety of data about pain characteristics, intensity, and stimulators; clinical signs and symptoms; and radiographic findings that should be collected prior to diagnosis making [11]. As well as, there is no standardization of these data in clinical and medical records which facilitates the understanding of clinical cases in initial and post-operative care.
However, digital technology can improve learning effectiveness and develop pedagogical practices more adapted to today's students [12]. New generations are increasingly more familiar with the use of symbology [13] making the use of digital technology more popular [14,15].
Pictograph are symbols used to convert messages and ideas into images that are clear and easy to understand without the use of text [16]. Relevant data of endodontic diagnosis can be converted into pictographs and grouped in three categories: pain characteristic (intensity, type, stimulator, location, duration and decline), clinical examination and radiographic examination. It would be sufficient to combine these data represented by an organized set of pictographs to provide a more accurate diagnosis and this results in a more objective treatment planning [12].
In order to enhance the dental students learning and facilitate the endodontic diagnosis making, this study aimed to evaluate the comprehension of a new pictograph system for endodontic diagnosis among undergraduate and graduate students/endodontists, as well as the intention of using it posteriorly.

The questionnaire
This study was realized at São Paulo State University, Institute of Science and Technology after approval of the research ethics committee (no 3.579.433).
To construct this questionnaire, an initial formulate was elaborated and presented to six students selected randomly to evaluate the ease of comprehension and interpretation. Once validated, a new formulate was elaborated considering the results of the initial one in improving the last one. The questionnaire was then destinated for undergraduate students (matriculated in pre-clinical and clinical disciplines of endodontics) and graduate students (Stricto sensu and Lato sensu) and endodontists.
A total of 224 participants were involved in this study and divided into two groups (Group 1: undergraduate students = 166 and group 2: endodontists and graduate students = 58). The participants received a presentation of the new pictograph system and then received the standardized questionnaire of three questions (Box.1).

Box 1 -
The final questionnaire presented to the participants.

Question
Answer 1 Answer 2

Which is the level of your education?
Undergraduate student Graduate student/ Endodontist 2. Which endodontic diagnostic method did you like?
The conventional method The pictograph method 3. Which endodontic diagnostic method you will use in your career after completing the course (conventional or pictograph)?
The conventional method The pictograph method

The conventional method of endodontic diagnosis
In this method, normally, dentists and dental students used to question the patient and fill in some standardized diagnostic sheets in order to obtain a final diagnosis of the pulp pathology. This method depends mainly on writing or typing the data collected by the patient for posterior analysis and diagnosis making.

The pictograph method of endodontic diagnosis
The same way in questioning the patient as in the conventional method. However, the clinical signs and symptoms and the radiographical findings are represented by symbols.
The symbols are grouped in three categories with the following items: 1. Pain characteristics subdivided into six groups of symbols (Figure 1   The professional while collecting the patient's data will use the ( ) symbol over the selected option. Later, these data will be analyzed by the professional and the diagnosis will be obtained. (Figure 4). This form could be used in digital or manual medical records.
The pictographs were elaborated using Corel Draw software (CorelDRAW, Ontario, Canada). In the first question, no statistical analyzing was realized, however, the percentage of the participants of each group was calculated.

RESULTS
The first question was to determine the level of education of the students in which 74.10% and 25.90% were undergraduate and graduate students/endodontists respectively.
In the second and third questions, after statistical analysis there was no significant difference between the groups in which in the second question: 71.08% and 62.06% of undergraduate and graduate student/ endodontists respectively preferred the pictograph method over the conventional diagnosis method, and in the third question: 60.24% and 51.72% of undergraduate and graduate students/endodontists respectively showed interest in using the pictograph method instead of using the conventional diagnosis method after graduation and in their professional career (Table.1).

Statistical analysis
The questionnaire data were collected and analyzed through multprop macro [17] using Tukey´s honest significant difference test with P ≤ 0.05. In the second and third questions, the answer "The pictograph method" was

DISCUSSION
The use of pictograph instead of written orders or messages has long been used in organized societies. This use tends to be even greater for new generations with the digital technology's revolution as applications and social networks. Currently digital technology is gaining a greater space in dental courses teaching through mobile applications [15] and virtual teeth [14].
In medical sciences, including medicine and pharmacy, pictographs are used to explain prevention and treatment information for patients [18] but with little focus on professional education and data organization in medical records. However, in dentistry and more specifically in endodontics, this use seems to be scarce. It is recommended to use pictographs in medical risk communication to improve people's risk comprehension and decision making [19].
This study presents a complete system to organize the endodontic diagnosis data. This system permits a more objective teaching, a more practical data organization, an easier communication among dental teachers, dental students and dentists in general, as the interprofessional communication in the field of dentistry affects patient satisfaction [20].
In this study, a questionnaire was made to evaluate the comprehension of a new pictograph system for diagnosis of pulp pathology among undergraduate and graduate students/endodontists. The results showed that undergraduate students were more open to accept the pictograph method. This group commented that the comprehension of the pictograph system was easier than the conventional method.
Pineda et al. [21] related that undergraduate decision-making is affected by academic training, in a study evaluated the undergraduate diagnosis of 15 endodontic cases after completing the endodontic discipline and one year later after completing their studies in implantology. The same results could be related in the present study, in which the training influences the decision-making. In this study, both groups received a presentation to clarify the definition of pictograph method and how it works.
In this study the graduate students/ endodontist were less interested than the undergraduate students in which fewer students selected the pictograph method in comparison to the undergraduate student's group. Still, the majority selected the pictograph method in both groups. This may be related to the experience of graduate students/endodontist having in diagnosis making and being more familiar with the conventional method. In this aspect, in a study evaluated the effects of specialty background and professional experience on decision making in endodontic diagnosis and treatment planning among professionals of diverse specialties, the endodontists showed the most consistent agreement among the specialty groups [2]. Even more in another study, a survey was realized to compare factors influence root canal retreatment strategies between dental specialists and general practitioners and found that the specialists decision making is affected by the experience as well [3].
On the other hand, 28.92 and 37.94 % of undergraduates and graduate students/ endodontist respectively selected the conventional method instead of pictograph method. Even more, some participants selected the pictograph method in the second question, however, in the third question declared no intention to use the pictograph method in their professional career. The negative response of some participants may be related to misunderstanding of the symbols, in this order, adoption requires education and consistency of use and placement [22].

CONCLUSIONS
Within the limitation of this study, the pictograph method in endodontic diagnosis is accepted by the majority of undergraduate and graduate students/endodontists. Training and experience affect the diagnosis decision.