DECISION SUPPORT AND TRAINING SYSTEM FOR MANAGEMENT OF ENDODONTICALLY TREATED TEETH By Anjali B Shah Dissertation Submitted to Rutgers University School of Health Related Professions In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy In Biomedical Informatics Department of Health Informatics October 2014 © 2014 Anjali B Shah All Rights Reserved i ii ABSTRACT Endodontically treated teeth are often structurally compromised and require proper prosthodontic restoration following endodontic therapy to ensure long-term success. As a result and as the number of endodontic procedures in contemporary dentistry have steadily increased in the past decade, tooth restoration is becoming an integral part of restorative practice in everyday dentistry. Although the subject has been widely researched and published in dental literature, the topic of best way to restore root canal treated teeth still remains an area prone to high error rates in decision-making. Complexity of the domain is largely due to multi-factorial considerations and need for evaluation of a wide range of restorative techniques of varying intricacies. Determining the best restorative treatment plan following endodontic therapy requires sound knowledge of principles that span across multiple dental disciplines of endodontics, orthodontics, periodontics, and prosthodontics. Memorization of a large and ever- increasing number of decision rules to be meaningfully used at the point-of-care can be arduous, especially for dental students and less experienced clinicians. Clinical experts with their knowledge and years of experience treating patients can help in the process, but may not always be around to provide assistance. Misdiagnosis and mistreatment of such teeth can lead to adverse clinical consequences and significant inconvenience to the patient as well as financial implications both for the patient and provider. To address this problem, we have developed a clinical decision support and training system based on expert knowledge and evidence-based guidelines. Using Corvid expert system development framework and careful consideration of factors necessary for success of clinical decision support systems, we have developed a working prototype of a web-based, interactive system that can be launched at the operatory and can be easily integrated into providers’ workflow. One of the important goals of the system is to train users to think holistically like an expert while problem-solving and planning restorative iii treatment. Based on information entered by the user, system comes up with recommendations, alerts and treatment prognosis. Treatment options provided with justifying explanations can help clinicians provide decision-making rationale to the patients, better inform and educate them, and thus better manage their expectations and ensure their satisfaction and compliance. Since the knowledge base of our system is developed using expert guidelines that are known to be effective, we expect to see improved restorative treatment outcomes for endodontically treated teeth. iv ACKNOWLEDGEMENTS First and foremost, I would like to express my gratitude to Dr. Louis DiPede from the Rutgers School of Dental Medicine for taking the time to serve as my thesis advisor, for original concept and ideas, helpful advice and for helping me gain practical insight into the field of restorative dentistry. I am indebted to Dr. Shankar Srinivasan for his kind and ever encouraging words, encyclopedic knowledge, fresh perspectives and countless useful conversations that have made a very positive and profound impact on my work. I can never thank enough my committee chair, Dr. Dinesh Mital, for his valuable guidance and insight throughout my graduate career. His influence has tremendously contributed to my development as a researcher. My sincere appreciation to Dr. Syed Haque, and Dr. Masayuki Shibata who have always been very supportive and encouraging and have helped me enlarge my sphere of understanding of Biomedical Informatics. Needless to say, my family truly deserves all the credit for what I am and where I am today. I thank my mother Dr. Bharati Shah, my father Dr. Bharat Shah, my father-in-law Mr. Balwant Nirmal, and my child’s baby-sitter Mrs. Halima Ali for all their love and support. I offer my greatest gratitude to my husband Suresh and my daughter Ariana, whose love, faith, and understanding carry me through life. v TABLE OF CONTENTS ABSTRACT ........................................................................................................................................ iii ACKNOWLEDGEMENTS .................................................................................................................... v Chapter 1 Introduction .................................................................................................................... 1 1.1 Introduction ........................................................................................................................... 1 1.2 Background and Statement of the Problem .......................................................................... 3 1.3 Significance of the Study ...................................................................................................... 10 1.4 Goals & Objectives of the Study .......................................................................................... 13 1.5 Hypotheses .......................................................................................................................... 15 Chapter 2 Literature Review .......................................................................................................... 17 2.1 Factors and Challenges in Restoration of Endodontically Treated Teeth ............................ 18 2.1.1 Fracture Resistance of Endodontically Treated Teeth .................................................. 18 2.1.2 Significance of Microleakage & Coronal Barrier ........................................................... 19 2.1.3 Significance of Full Cuspal Coverage ............................................................................. 20 2.1.4 Caries management ...................................................................................................... 21 2.1.5 Significance of Remaining Coronal Tooth Structure ..................................................... 22 2.1.6 Significance of Biologic Width ....................................................................................... 24 2.1.7 Significance of Ferrule Effect ........................................................................................ 26 2.1.8 Significance of Occlusal Forces ..................................................................................... 28 2.1.9 Principles in the Use of Post and Core System ............................................................. 30 2.1.9.1 Need for Posts in Endodontically Treated Teeth ................................................... 30 2.1.9.2 Type of Posts and Post Design ............................................................................... 32 2.1.9.3 Post Space Preparation Considerations ................................................................. 34 2.1.9.4 Core Materials ........................................................................................................ 36 2.1.9.5 Final Restoration .................................................................................................... 38 2.2 Review of Clinical Decision Support Systems....................................................................... 39 2.2.1 Definition and Concept of Computer-based Clinical Decision Support Systems .......... 39 2.2.2 Historical Perspective .................................................................................................... 40 2.2.2.1 Clinical Decision Support Systems in Medical Field ............................................... 40 2.2.2.2 Clinical Decision Support Systems in Dentistry ...................................................... 46 2.2.3 Characteristics and Types of Clinical Decision Support Systems .................................. 51 vi 2.2.4 Clinical Decision Support Systems in Restorative Dentistry ......................................... 62 2.3 Importance and Effectiveness of Technology in Dental Education ..................................... 65 Chapter 3 System Design and Implementation ............................................................................. 68 3.1 System Architecture ............................................................................................................. 69 3.2 Rationale for Choosing Exsys Corvid .................................................................................... 80 3.3 User Interaction Process Flow ............................................................................................. 81 3.4 System Design and Implementation .................................................................................... 84 3.4.1 Logical System Flow ...................................................................................................... 84 3.4.2 Rule-based Knowledge Representation ........................................................................ 94 Chapter 4 Results and Case Studies ............................................................................................. 104 4.1 Preliminary System Testing ................................................................................................ 104 4.2 System