|Year : 2013 | Volume
| Issue : 2 | Page : 77-81
Radiographic assessment of quality of root fillings performed by undergraduate students in a Malaysian Dental School
Pishipati Vinayak Kalyan Chakravarthy, Jeyavel Rajan Karuna Moorthy
Department of Conservative Dentistry and Endodontics, Penang International Dental College, Butterworth 12000, Penang, Malaysia
|Date of Web Publication||13-Sep-2013|
Pishipati Vinayak Kalyan Chakravarthy
Department of Conservative Dentistry and Endodontics, Penang International Dental College, 18-21 floors, New Bob Towers, Jalan Bagan Luar, Butterworth 12000, Penang
Source of Support: None, Conflict of Interest: None
Objective: The aim of the study was to assess the radiographic quality of root ﬁllings done by the undergraduate students. Materials and Methods: A sample of 258 clinical cases of patients who received root canal treatment from undergraduate students in the years 2010 to 2012 were selected, out of which 194 root fillings were assessed radiographically based on the following criteria; length and density of root filling. Root fillings were categorized as acceptable and unacceptable. Percentages and χ² test were used for statistical analysis. Results: From the 194 root fillings, 119 (61.35%) were having acceptable and 75 (38.65%) were having unacceptable root fillings. From the total 75 unacceptable root fillings, 49 (65.33%) had density problems, 11 (14.66%) were overfilled, and 15 (20%) were under filled. Chi-square test was done for statistical analysis; revealed no significant difference in the radiographic quality between anterior and posterior root fillings. Conclusion: The radiographic quality of root fillings done by undergraduate students was acceptable in 61.35% cases. Most common cause of unacceptable fillings was due to density problems compared to overfilling and under filling. Results from the study indicate that remedial measures have to be undertaken to improve training of undergraduate students in root canal treatment procedure.
Keywords: Radiographic assessment, root fillings, technical quality, undergraduate students
|How to cite this article:|
Chakravarthy PK, Moorthy JK. Radiographic assessment of quality of root fillings performed by undergraduate students in a Malaysian Dental School. Saudi Endod J 2013;3:77-81
|How to cite this URL:|
Chakravarthy PK, Moorthy JK. Radiographic assessment of quality of root fillings performed by undergraduate students in a Malaysian Dental School. Saudi Endod J [serial online] 2013 [cited 2019 Dec 8];3:77-81. Available from: http://www.saudiendodj.com/text.asp?2013/3/2/77/118155
| Introduction|| |
The prognosis of the root canal treatment depends on many variables and among them is the technical quality of the root fillings, which plays a significant role as demonstrated by epidemiological studies. These studies report high prevalence of apical pathosis associated with root filled teeth, particularly when the root filling was inadequate. ,, The quality of root fillings have an important bearing on the periapical health and healing. , Systematic evaluation of quality of root filling is essential for the clinicians to estimate prognosis. The method mostly used to determine the technical outcome of root canal treatment is radiographic evaluation.  The radiological evaluation of quality of root canal filling is relatively easy, since filling in the canals provide good contrast. This facilitates good evaluation of degree to which filling obturates the canal, its density, and homogeneity. Researchers have proven a direct relationship exist between poor quality of root filling and the radiological changes in apical periodontium characteristic to apical periodontitis.  One reason cited for the relatively poor technical standards of root canal treatment (RCT) among the general practitioners may be the limited endodontic teaching received at dental schools. , Studies on technical quality of root filling done by undergraduate students are necessary to assess the effectiveness of endodontic training given in dental schools and also help to take measures to improve future training in this discipline. The purpose of the present study was to assess the technical quality of root fillings completed by the undergraduate students in dental school in Malaysia as there are no published studies in this respect.
| Materials and Methods|| |
The study was carried out with the approval of the ethical committee of Penang International Dental College, Malaysia.
At our dental school, undergraduate students in Endodontics must complete a preclinical course, which includes both theoretical (20 hours) and practical laboratory training (40 hours). This course is held during second semester of year 3 and first semester of year 4 of dental degree program, which lasts for 5 years overall. It is necessary for students to complete preclinical laboratory exercises of RCT on extracted maxillary and mandibular teeth. Students will be allowed to perform RCT on patients only after completion of required quota of preclinical work and assessment by staff. Students perform RCT in second semester of year 4 and first and second semesters of year 5 of the dental degree program.
RCT was performed by students according to following protocol:
After consideration of medical and dental history of patient, local anesthesia was administered if needed. The tooth to be treated was isolated by rubber dam, access prepared and working length was determined using K files and Ingle's radiographic method. Each root canal was instrumented with step back method using 0.02 taper stainless steel K files. In some cases, the coronal third of the root canals were shaped with Gates-glidden drills to facilitate straight line access. Glyde (Dentsply, USA) was used as lubricant, and canals were irrigated with 3% NaOCl using 27 gauge needles during all stages of cleaning and shaping.
All the root canals were filled with 0.02 taper guttapercha cones and AH Plus sealer (Dentsply, USA) following cold lateral condensation technique.
For this retrospective study, sample was obtained from the dental records and intraoral periapical radiographs of patients who had received RCT from the undergraduate students. A total of 258 clinical cases of root canal-treated teeth done between 2010 and 2012 were randomly selected to assess the technical quality of root ﬁllings performed by undergraduate students of batch 2008 intake who had same amount of preclinical training. Out of this, only 194 clinical cases which fulfilled the criterion of radiographic assessment as stated below were chosen, others were excluded for one of many reasons of not fulfilling the requirements.
Criteria of radiographic assessment
Analysis of post-obturation radiographs
- Only immediate post-obturation radiographs of good quality were selected, where the root filling was clearly visible
- Radiographs with fixer stains, poorly developed, overdeveloped or with any other processing errors were excluded
- If a clinical case lacks the final post-obturation radiograph after placement of either a temporary or permanent restoration, such cases were not taken into consideration, and categorized under missing radiographs category
- In cases where the root canal shaping and filling were done with protaper systems were excluded.
Two variables were examined: The length and the density of the root ﬁllings. Results were categorized as acceptable and unacceptable and subcategorized under the unacceptable category as those with density problems, under filled, and overfilled. For each root canal-treated tooth, only one post-obturation radiograph is assessed under an x-ray viewer with magnification, and each radiograph is separately assessed by two examiners based on definite criteria for radiographic interpretation as given below [Table 1]  . Two examiners both specialized in Endodontics with five years of clinical and teaching experience, examined the radiographs. Before evaluation, both the examiners participated in a calibration session examining few post-obturation radiographs reviewing the defined criteria.
The results obtained were compared, and a final evaluation was agreed. In case of disagreement, the two examiners discussed the case to reach a consensus.
The results were described as percentages. Chi-square test was applied for the association of variables, and the significant level was established at 5% (P < 0.05).
| Results|| |
From the total sample size of 258 clinical cases of RCT assessed, a total of 64 clinical cases were excluded as it did not meet the study criteria that were stated previously. Upon exclusion, a total of 194 root fillings that met the criteria stated were analyzed. From the 194 root fillings, 119 (61.35%) had an acceptable radiographic quality of root fillings. The frequency of acceptable fillings was greater in anterior teeth (64.9%) than in posterior teeth (54%) [Table 2]. Out of total 75 unacceptable root fillings, 49 (65.33%) had density problems, 11 (14.66%) overfilled, and 15 (20%) were under filled [Table 3]. Density problem was the most common reason of unacceptable root fillings in anterior (73.9%) and posterior teeth (51.7%).
|Table 2: Radiographic quality of root fillings done by undergraduate students|
Click here to view
Chi-square test was done for statistical analysis; revealed no significant difference in the radiographic quality between anterior and posterior root fillings (P > 0.05).
| Discussion|| |
The technique for obturation of the root canal systems taught to undergraduate students in our dental school is the cold lateral condensation technique. This technique is the most widely taught and used technique even in the United States Dental Schools.  Methods used to evaluate the technical outcome of RCT in the past have been based mostly on radiographic evaluation. , According to the consensus report of the European Society of Endodontolgy, , an appropriate root canal filling should radiographically show a prepared root canal space filled completely without space between the filling and the canal walls and it should be placed within 0.5-2.0 mm of the radiographic apex to prevent post-treatment disease. Root fillings placed within 0-2 mm of the radiographic apex are associated with less post-treatment disease than those that are filled with a distance more than 2 mm from the radiographic apex. , Sjogren et al. and Smith et al. have reported that the length of the root filling, relative to the radiographic apex, significantly affected the outcome of RCT with 87%  and 94%  healing rates associated with root filling ending 0-2 mm from the radiographic apex. Poor quality of root fillings in relation to the length and density entails a high risk of failure of the root canal treatment that may result in progressing or persistent periradicular pathosis.
In our study, it was found that 61.35% of root fillings done by undergraduate students were acceptable. This value obtained was lower compared to other studies done on quality of root fillings by undergraduate students, which were 76% reported by Al-Yahya  and 70% by Lynch et al.  On the contrary, it was higher than the 47% reported by Barrieshi-Nusair et al., 55% reported by Eleftheriadis et al., 13% reported by Hayes et al., 23% reported by Balto et al., and 33% reported by Er et al., Nevertheless, it is difficult to compare these studies because of different criteria used. In some studies, teeth were categorized as posteriors and anterior while in others as posteriors are further categorized as premolars and molars.
In our study, 64.9% of anterior root filling and 54% of posterior root fillings were acceptable. This result was consistent with most other similar studies of Balto et al.  and Eleftheriadis et al., which also found that the frequency of teeth with an acceptable root fillings were significantly greater in the anterior teeth (74%) than in posterior teeth. This may be explained partly by the simpler root canal anatomy of single-rooted anterior teeth, which mostly have one large canal leading down to the apex of the tooth.
In our study among unacceptable fillings, density problems accounted for 65.3% compared to overfilled at 14.6% and under-filled at 20%. Studies that addressed the lateral condensation technique of the root filling as a criterion generally agreed that if voids were present between the filling and/or the canal walls, the filling should be categorized as inadequate. ,, Kirkevang et al. reported that inadequate density may lead to failure of RCT because of microleakage along the root filling. Similarly, Eriksen et al. stated that the prevalence of apical periodontitis was higher in root-filled teeth with poor densities. The correlation between density of the root filling and prognosis is not as clear as the proximity of the root filling to the radiographic apex. Several studies have reported no difference in prognosis between adequately and inadequately compacted root fillings. , Whilst others have found that a root filling that is less dense and non-homogenous will have a negative impact on the outcome. ,, Chugal et al. demonstrated that root fillings with homogenous mass of filling material and with no voids are strongly correlated with a lower risk of post-treatment disease.
The relatively lower percentage of acceptable root canal fillings assessed in this study could be attributable to many reasons. These may include factors such as the design of the study, the criteria followed, the conventional techniques used for RCT in the clinics, and the clinical requirements. Whilst the technical quality of root fillings, as portrayed by radiographs, is important for the outcome of the treatment, it may not reflect the quality of the treatment in general. Factors other than radiographic quality must be considered when determining the outcome of root canal therapy. , The antiseptic and aseptic efforts during treatment, quality of canal preparation, materials used and treatment routines including anti-bacterial regimen are amongst many prognostic factors that remain inconclusive from epidemiological studies. 
The students in our dental school use stainless steel files and cold lateral condensation technique. In many schools in United States and Europe, usage of Ni Ti files has been incorporated in to their preclinical training. Studies have reported reduced errors during root canal treatment when students used Ni Ti instruments. ,
An audit of quality of root fillings done by undergraduate students is an important aspect of quality assurance in dental schools. The results of the present study suggests that there is a need to review the endodontic curriculum requirements, increase in duration of preclinical and clinical training, improvement in staff-student ratio, incorporation of student self-assessment, and introduction of rotary Ni Ti files and warm guttapercha condensation techniques in preclinical and clinical training.
| Conclusion|| |
Within the limitations of this study, the radiographic quality of root fillings done by undergraduate students was acceptable in 61.35% cases. Quality of root fillings was better in anterior teeth than in posterior teeth. Most common cause of unacceptable fillings was due to density problems compared to overfilling and under filling. Results from the study indicate that remedial measures have to be undertaken to improve training of undergraduate students in root canal treatment procedure.
| References|| |
|1.||Dugas NN, Lawerence HP, Teplitsky PE, Pharoah MJ, Friedman S. Periapical health and treatment quality assessment of root-filled teeth in two Canadian populations. Int Endod J 2003;36:181-92. |
|2.||Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long term results of endodontic treatment. J Endod 1990;16:498-504. |
|3.||Smith CS, Setchell DJ, Harry FJ. Factors influencing the success of conventional root canal therapy: A five year retrospective study. Int Endod J 1993;26:321-33. |
|4.||Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J 2002;35:229-38. |
|5.||Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J 1997;182:382-6. |
|6.||Er O, Sagsen B, Maden M, Cinar S, Kahraman Y. Radiographic technical quality of root fillings performed by dental students in Turkey. Int Endod J 2006;39:867-72. |
|7.||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. |
|8.||Barrieshi-Nusair KM, Al-Omari MA, Al-Hiyasat AS. Radiographic technical quality of root canal treatment performed by dental students at the Dental Teaching Centre in Jordan. J Dent 2004;32:301-7. |
|9.||Qualtrough AJ, Whitworth JM, Dummer PM. Preclinical endodontology: An international comparison. Int Endod J 1999;32:406-14. |
|10.||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. |
|11.||Cailleteau JG, Mullaney TP. Prevalence of teaching apical patency and various instrumentation and obturation techniques in United States dental schools. J Endod 1997;23:394-6. |
|12.||Buckley M, Spangberg LS. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:92-100. |
|13.||Undergraduate curriculum guidelines for Endodontology. Int Endod J 2001;34:574-80. |
|14.||Consensus report of the European Society of Endodontology on quality guidelines for endodontic treatment. Int Endod J 1994;27115-24. |
|15.||Boltacz-Rzepkowska E, Pawlicka H. Radiographic features and outcome of root canal treatment carried out in the Lodz region of Poland. Int Endod J 2003;36:27-32. |
|16.||Al-Yahya AS. Analysis of student's performance and gender in an undergraduate endodontics' program. Saudi Dent J 1990;2:58-61. |
|17.||Lynch CD, Burke FM. Quality of root canal fillings performed by undergraduate students on single rooted teeth. Eur J Dent Educ 2006;10:67-72. |
|18.||Hayes SJ, Gibson M, Hammond M, Bryant ST, Dummer PM. An audit of root canal treatment performed by undergraduate students. Int Endod J 2001;34:501-5. |
|19.||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. |
|20.||Kirkevang LL, Horsted-Bindslev P, Ostravik 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. |
|21.||Eriksen HM, Bjertness E. Prevalence of apical periodontitis and results of endodontic treatment in middle-aged adults in Norway. Endod Dent Traumatol 1991;7:1-4. |
|22.||Marques MD, Moreira B, Eriksen HM. Prevalence of apical periodontitis and results of endodontic treatment in an adult, Portuguese population. Int Endod J 1998;31:161-5. |
|23.||Chugal NM, Clive JM, Spangberg LS. Endodontic infection: Some biologic and treatment factors associated with outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:81-90. |
|24.||Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod 1979;5:83-90. |
|25.||Stoll R, Betke K, Stachniss V. The influence of different factors on the survival of root canal fillings: A 10-year retrospective study. J Endod 2005;31:783-90. |
|26.||Eriksen HM, Kirkevang LL, Petersson K. Endodontic epidemiology and treatment outcome: General considerations. Endod Topics 2002;2:1-9. |
|27.||Kelbauskas E, Andriukaitiene L, Nedzelskiene I. Quality of root canal filling performed by undergraduate students of odontology at Kaunas University of Medicine in Lithuania. Stomatologija 2009;11:92-6. |
[Table 1], [Table 2], [Table 3]
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