|Year : 2013 | Volume
| Issue : 1 | Page : 25-30
Endodontic mishaps among undergraduate dental students attending King Saud University and Riyadh Colleges of Dentistry and Pharmacy
Diemah F Alhekeir1, Rana A Al-Sarhan1, Hussein Mokhlis2, Saad Al-Nazhan3
1 Department of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia
2 Department of Endodontics, Prince Sultan Military Medical City, Dental Clinics, Riyadh, Saudi Arabia
3 Department of Restorative, Dental Sciences, Division of Endodontics, King Saud University, College of Dentistry, Riyadh, Saudi Arabia
|Date of Web Publication||7-Aug-2013|
Diemah F Alhekeir
P.O. Box 10530, Riyadh, 11443
Source of Support: None, Conflict of Interest: None
Aim: The purpose of this study was to investigate procedural errors occurring during conventional root canal treatment performed by undergraduate students attending two dental schools in Riyadh, Saudi Arabia. Materials and Methods: A cross-sectional survey was distributed to 600 undergraduate dental students from the Riyadh Colleges of Dentistry and Pharmacy (RCsDP) and the College of Dentistry at King Saud University (KSU) in Riyadh, Saudi Arabia. Participants were senior male and female dental students from the 4 th to 6 th years at RCsDP and the 4 th to 5 th years at KSU. Participants were asked to record their endodontic mishaps; these data were analyzed using IBM SPSS software. Chi-square (X2 ) tests were carried out to compare pairs of groups; significance was established at 5% (p < 0.05). Results: The percentage of endodontic mishaps was 68%. The majority of students who made endodontic mishaps were male (73.6%) (X2 =8.74, =0.002). Most mishaps occurred in the posterior area (63.96%) and those with curved roots (39.46%). Conclusion: The frequency of endodontic mishaps occurring at both schools was found to be higher in 4 th year students from KSU, but this dramatically decreased in the 5 th year. Variable results were obtained from the RCsDP 4 th year students, but they did not improve in the 5 th and 6 th year. We believe that the use of step-down techniques utilizing flexible nickel titanium files and more training in the lab will cause potentially fewer procedural complications at both schools.
Keywords: Endodontic, mishaps, undergraduate dental students
|How to cite this article:|
Alhekeir DF, Al-Sarhan RA, Mokhlis H, Al-Nazhan S. Endodontic mishaps among undergraduate dental students attending King Saud University and Riyadh Colleges of Dentistry and Pharmacy. Saudi Endod J 2013;3:25-30
|How to cite this URL:|
Alhekeir DF, Al-Sarhan RA, Mokhlis H, Al-Nazhan S. Endodontic mishaps among undergraduate dental students attending King Saud University and Riyadh Colleges of Dentistry and Pharmacy. Saudi Endod J [serial online] 2013 [cited 2020 Sep 26];3:25-30. Available from: http://www.saudiendodj.com/text.asp?2013/3/1/25/116277
| Introduction|| |
Root canal treatment (RCT) is usually aimed to maintain or restore the health of the dental pulp and periradicular tissues. The outcome of the therapy depends on the operator's ability to perform the whole procedure without making any mistakes.
Endodontic mishaps, which occur during diagnosis, access preparation, instrumentation, obturation, and post-space preparation, make treatment completion difficult and jeopardize treatment outcomes. ,,
Dummer 1991 compared undergraduate endodontic teaching programs in Britain to those in United State and reported that one of the causes of poor quality endodontic treatment in general practice was lack of expertise and a poor understanding of the principles involved by the graduated students.  Similar findings were reported in Arabic countries such as Jordan  and Sudan.  Barrieshi-Nusair related this to the endodontic teaching at the dental schools in these countries. 
The dental college of King Saud University (KSU) was the first government dental school in the Kingdom of Saudi Arabia, established in 1976. Students in their 4 th and 5 th year practice non-surgical endodontics on a variety of teeth under the close supervision of the endodontic staff. A few studies have evaluated the endodontic performance of KSU students; ,, both reported acceptable results regardless any mishaps that occurred during the treatment. In the other hand, Riyadh Colleges of Dentistry and Pharmacy (RCsDP) was the first private dental school in the Kingdom of Saudi Arabia established in 2004. Similar to KSU, students in their 4 th to 6 th years practice non-surgical endodontics under the close supervision of the endodontic staff. No studies have yet been published that evaluate the RCsDP student's performance in non-surgical endodontic therapy. In addition, we believe that a comparison of students' mishaps at both schools could be informative; therefore, the present cross-sectional study was conducted to investigate procedural errors occurring during conventional root canal treatment performed by undergraduate students attending KSU and RCsDP dental schools.
| Materials and Methods|| |
A cross-sectional survey was distributed to 600 male and female undergraduate dental students from KSU and RCsDP in Riyadh, Saudi Arabia. Participants were senior male and female dental students from the 4 th to 6 th years at RCsDP and the 4 th to 5 th years at KSU. A self-administered questionnaire was designed and used for data collection following a comprehensive literature review. The questionnaires were distributed to all the participants to record any endodontic mishaps they had faced since beginning their clinical practice. Participation was voluntary; all information remained confidential. The study design was reviewed and approved by the institutional ethics committee of both schools.
The questionnaire was composed of seven closed-ended questions, which requested information relating to the student and the patient, the position and anatomy of the teeth, type of root canal procedure, the types of mishaps, and the steps during which they occurred.
Descriptive statistics were used for the data analysis; Chi-square tests (X2) were used with a significance level of 5% (P < 0.05). The data were analyzed by using IBM SPSS software (version 16; IBM, Armonk, NY, USA).
| Results|| |
Results are summarized in [Table 1] and [Table 2] and [Figure 1].
|Tabel 1: Endodontic mishaps that occurred between male and female students |
Click here to view
|Table 2: Summary of the frequency of endodontic mishaps of different procedures at both schools |
Click here to view
|Figure 1: Endodontic mishaps related to the position and anatomy of the dentition|
Click here to view
A total of 560 undergraduate dental students (93.33%) responded to the questionnaire (295 male and 265 female students). The percentage of endodontic mishaps among undergraduate students from both dental schools was 68%. The majority of undergraduate dental students (93.7%) used the step-back technique with hand instrumentation and lateral condensation filling using gutta-percha and AH26 resin paste sealer. Few students practice the crown-down technique (6.3%). Chi-square analysis revealed that the majority of students who made endodontic mishaps were male (73.6%, n = 217) compared to female students (61.9%, n = 164) (χ 2 = 8.74; P = 0.002). Further, there was a significant decrease in the percentage of mishaps when students treated patients of an opposite gender (χ 2 = 1.21; P = 0.000). Nearly two-thirds (63.96%) of the endodontic mishaps occurred in the posterior dentition. In comparison, the anterior dentition and premolars were involved in 20.17% and 33.93% of mishaps, respectively. The frequency of mishaps was the highest among teeth with curved roots (39.46%). There was no significant difference in the number of mishaps between the upper and lower arches [Figure 1].
When the proportion of endodontic mishaps by male and female students were compared, female students were found to make the greatest number of gouging during access cavity preparation (59.3%), while ledge formation occurring during root canal instrumentation was highest among male students (56.7%). The frequency of voids during obturation as well as removing more gutta-percha during post-space preparation was high in both female and male students; both mishaps were more common among female students (42.9% and 48.4%, respectively). Chi-square tests revealed no significant relationships between male and female students regarding the types of endodontic mishaps [Table 1].
For the frequency of endodontic mishaps at both schools, we found that the 4 th year students at KSU had a higher frequency of endodontic mishaps, but this decreased in the 5 th year [Table 2]. Results from the RCsDP regarding the frequency of endodontic mishaps were variable: the frequency was higher at the RCsDP compared to KSU in general, but it did not improve in the 5 th and 6 th year.
| Discussion|| |
Endodontic treatment can be considered a stressful procedure for undergraduate students. It usually requires competent technical skills and experience, as well as an understanding of pulp anatomy and its variations. Knowledge of root canal morphology and tooth pulp chamber will allow the student to avoid any mishaps. In many cases, insufficient knowledge makes endodontics more difficult than necessary by not creating a proper access that allows straight line approach to the canals. This is especially true for mesiobuccal canals in both molar teeth. Perforation of pulp chamber can occur during a fruitless search for the canal orifices, drilling a tooth with a completely calcified chamber, orienting the bur to the wrong direction, or looking in the wrong direction for the other canal. Students from both schools reported gouging and perforation during access cavity preparation. This is considered normal for undergraduate student.
Endodontic treatment is most frequently performed on the first molar teeth. In the present survey, we found that 63.96% of mishaps occurred in the posterior dentition. Similar; finding were reported by Balto et al. based on radiographic examination at KSU. We believe this is caused by the increased canal curvature of these teeth, which can be negatively affected during root canal instrumentation. Most students at both schools performed the step-back instrumentation technique, which involves preparation of the apical region of the root canal followed by coronal flaring.  Stainless steel files are usually used for this technique. However, instrumenting curved canals using this technique often results in iatrogenic damage to the normal shape of the canal, such as ledge formation or the blockage of canals by dentin plugs. This due to the inherent inflexibility of the stainless steel files. ,
The narrow and curved canals of molar teeth usually make RCT more challenging. In the present study, students from both schools had ledged the canals in about 55% of teeth. This percentage is almost similar to that reported by Kapalas and Lambrianidis  and slightly higher than that reported by Greene and Krell,  Eleftheriadis and Lambrianidis.  Al-Yahya,  Balto et al.  and Al-Kahtani  of KSU, however, reported lower percentages of ledged canals than in our study. They evaluated radiographic films of students which gives two dimensional view, whereas in our study, students were only asked whether they had ledged the canals during their clinical practice. Furthermore, students are supervised by endodontic faculties who check each step during the clinical session and inform the students of any mistake.
In order to reduce the incidence of iatrogenic defects, step-down technique is recommended for undergraduate students. This technique depends on the use of larger instruments at the canal orifice during preparation, then working down the root canal with progressively smaller files. , This offers several advantages, including straighter access to the apical region and enhanced tactile control, as well as improved irrigant penetration and suspension of debris. Using this approach, most of the problems that occur during root canal instrumentation can be avoided. ,
In the current study, we found that the majority of students who experienced endodontic mishaps were male, similar to the finding reported by Al-Yahya  in his study performed at KSU. This might be related to the extensive physical force used by the male (compared to the female students) during treatment; all endodontic treatments should be carried out gently to prevent the incidence of mishaps. In contrast, Balto et al.,  Kerekes and Tronstad,  and Sjögren et al.,  found no gender-related differences in endodontic treatment outcomes.
Consistent with our findings, Khbbaz  stated the need for improvement in the technical quality of root fillings performed by undergraduate students, especially in molar teeth. The quality of root canal filling is very important for better outcome results. Inadequate density may lead to failure of RCT due to microleakage along the root filling (Kirkevang et al.  In addition, Eriksen and Bjertness  reported that the prevalence of apical periodontitis was higher in root filled teeth with poor densities. The result of the present evaluation indicated that most of the students were satisfied by their root canal filling performance. The most common mistake was voids (46%), which mostly occurred during the first clinical course. This is similar to findings from Al-Kahtani  and Balto et al. 
Students from KSU improved themselves as they moved to higher level which agrees with the findings of Balto et al.  In contrast, RCsDP students did not improve; their incidence of mishaps did not change. This could be related to the low number of cases treated, the student's evaluation procedure (the point system) or not enough supervision by endodontic staff. Students at the RCsDP begin their laboratory sessions at levels 6 and 7. They should finish three cases in each level starting with single root, then two root, and molar teeth; using lateral condensation. At KSU, students start their laboratory sessions during the 3 rd year. Students should finish 3 anterior, two premolar and 3 molar teeth using the same filling technique of RCsDP School. In addition, students should practice the access opening and locating of root canal orifices on similar number of teeth as well as retreatment, filling the canal with calcium hydroxide and post space preparation. 
During clinical sessions, the system at RCsDP is not based on clinical requirements; instead, a points system is used for evaluation. Each year, students must collect a certain number of points. For example, students can earn 10 points for performing one canal RCT but 20 points for a retreatment of one canal. We think that the student should have requirements to finish which will ensure better training by treating all type of teeth. At KSU, students start their clinical sessions during the 4 th year. Students should finish 2 to 3 anterior, 2 premolar and 2 to 3 molar teeth.  Students of KSU continue the practice of RCT in their final year under close supervision of the endodontic staff, with no required number of cases to complete. It is based on the case that they have to do full mouth rehabilitation if it has teeth to do the RCT or not. 
Most often, endodontically treated teeth are rehabilitated with a post and crown. At least 4 to 5 mm of gutta-percha should be left apically in the root canal.  Careful removal of the gutta-percha filling during post preparation is very important to guarantee an adequate apical seal and prevent leakage.  Most students of both schools removed more of the gutta-percha when preparing the canal for post placement. We believe that students from neither school received adequate training on post preparation methods.
Finally, Cross-sectional studies are observational in nature: they provide a ''snapshot'' of a group of participants at one point in time. The analysis is usually restricted to the available information and is vulnerable to biases of interpretation. In some investigators' opinions, these biases are reduced in comparison to longitudinal studies. ,
We evaluated 600 students and this is one of the greatest advantages of cross-sectional studies where enough information can be gathered. This large sample sizes have the potential to dilute interpretation biases.
| Conclusion|| |
Root canal treatment presents a great challenge to a dental student where mishaps commonly occurred. The frequency of endodontic mishaps at both schools we studied was found to be higher in the 4 th year students of KSU but this dramatically decreased in the 5 th year. Variable results were obtained from the 4 th year students at the RCsDP but they did not improve in their 5 th and 6 th years. Endodontic mishaps could be avoided with thorough knowledge of the complications and variations in root canal anatomy, excellent training, good technical skills and abundant supervision from a clinical supervisor. In addition, we believe that the use of step-down techniques with a flexible nickel titanium files could result in fewer procedural complications.
| Acknowledgments|| |
The authors thank Prof. Hezekiah A. Mosadomi for assistance in conducting this research, and Dr. Rehab Nizam and Dr. Abeer Al.Henaki who assisted with the distribution of the questionnaire. Further, we greatly appreciate the assistance of Mr. Nassr Al.Maflehi, who analyzed the data.
| References|| |
|1.||Mozayeni M, Asnaashari M, Modaresi S. Clinical and radiographic evaluation of procedural accidents and errors during root canal therapy. Iran Endod J 2006;1:97-100. |
|2.||Crump M, Natkin E. Relationship of broken root canal instruments to endodontic case prognosis: a clinical investigation. J Am Dent Assoc 1970;80:1341-7. |
|3.||Karabucak B, Setzer F. Criteria for the ideal treatment option for failed endodontics: Surgical or nonsurgical. Compend Contin Educ Dent 2007;28:304-10. |
|4.||Dummer PM. Comparison of undergraduate endodontic teaching programs in the United Kingdom and in some dental schools in Europe and the United States. Int Endod J 1991;24:169-77. |
|5.||Barrieshi-Nusair KM, Al-Omari MA, Al-Hiyasat AS. Radiographic technical quality of root canal treatment performed by dental students at the Dental Teaching Center in Jordan. J Dent 2004;32:301-7. |
|6.||Elsayed RO, Abu-Bakr NH, Ibrahim YE. Quality of root canal treatment performed by undergraduate dental students at the University of Khartoum, Sudan. Aust Endod J 2011;37:56-60. |
|7.||Al-Yahya AS. Analysis of the students′ performance and gender in an undergraduate endodontics′ program. Saudi Dent J 1990;2:58-61. |
|8.||Balto H, Al Khalifah Sh, Al Mugairin S, Al Deeb M, Al-Madi E. Technical quality of root fillings performed by undergraduate students in Saudi Arabia. Int Endod J 2010;43:292-300. |
|9.||Al-Kahtani A. Radiographic technical quality of root canal treatment performed by undergraduate students at college of dentistry, King Saud University. J Pak Dent Assoc 2009;18:162-6. |
|10.||Mullaney TP. Instrumentation of finely curved canals. Dent Clin North Am 1979;23:575-92. |
|11.||Weine FS, Kelly RF, Lio PJ. The effect of preparation procedures on original canal shape and on apical foramen shape. J Endod 1975;1:255-62. |
|12.||Gambill JM, Alder M, del Rio CE. Comparison of nickeltitanium and stainless steel hand-file instrumentation using computed tomography. J Endod 1996;22:369-75. |
|13.||Kapalas A, Lambrianidis T. Factors associated with root canal ledging during instrumentation. Dent Traumatol 2000;16:229-31. |
|14.||Greene KJ, Krell KV. Clinical factors associated with ledged canals in maxillary and mandibular molars. Oral Surg Oral Med Oral Path 1990;70:490-7. |
|15.||Eleftheriadis GI, Lambrianidis TP. Technical quality of root canal treatment and detection of iatrogenic errors in an undergraduate dental clinic. Int Endod J 2005;38:725-34. |
|16.||Goerig AC, Michelich RJ, Schultz HH. Instrumentation of root canals in molars using the step-down technique. J Endod 1982;8:550-4. |
|17.||Fava LR. The double-flared technique: an alternative for biomechanical preparation. J Endod 1983;9:76-80. |
|18.||Weine FS, Kelly RF, Lio PJ. The effect of preparation procedures on original canal shape and on apical foramen shape. J Endod 1975;1:255-62. |
|19.||Al-Omari MA, Dummer PM. Canal blockage and debris extrusion with eight preparation techniques. J Endod 1995;21:154-8. |
|20.||Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod 1979;5:83-90. |
|21.||Sjögren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990;16:498-504. |
|22.||Khabbaz MG, Protogerou E, Douka E. Radiographic quality of root fillings performed by undergraduate students. Int Endod J 2010;43:499-508. |
|23.||Kirkevang LL, Horsted-bindslev P, Orstavik D, Wenzel A. A comparison of the quality of root canal treatment in two Danish subpopulations examined 1974-75 and 1997-98. Int Endod J 2001;34:607-12. |
|24.||Eriksen HM, Bjertness E. Prevalence of apical periodontitis and results of endodontic treatment in middle-aged adults in Norway. Dent Traumatol 1991;7:1-4. |
|25.||Al-Obaida M. RDS 322 Pre-clinical Endodontics. Available from: http://faculty.ksu.edu.sa/alobaida/Pages/322RDSOutline.aspx. [Last accessed in 2013]. |
|26.||Al-Nazhan S. RDS 423 Clinical Endodontics. Available from: http://faculty.ksu.edu.sa/alnazhan/Documents/423RDS%20 COURSE%20REQUIREMENTS.pdf. [Last accessed in 2013]. |
|27.||Al-Zain S. DEN 491 Comprehensive Clinical Dentistry. Available from: http://faculty.ksu.edu.sa/6809/Pages/den491.aspx. [Last accessed in 2013]. |
|28.||Madison S, Zakariasen KL. Linear and volumetric analysis of apical leakage in teeth prepared for posts. J Endod 1984;10:422-7. |
|29.||Ricci ER, Kessler JR. Apical seal of teeth obturated by laterally condensed gutta-percha the thermafil plastic and thermafil metal obturator techniques after post space preparation. J Endod 1994;20:123-6. |
|30.||Altman DG. Practical statistics for medical research. London: Chapman and Hall; 1991. |
|31.||Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias TS. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod 1988;14:261-6. |
[Table 1], [Table 2]