|Year : 2014 | Volume
| Issue : 1 | Page : 18-22
Knowledge and attitude of endodontic postgraduate students toward sterilization of endodontic files: A cross-sectional study
Arun Aslam1, Venugopal Panuganti1, Jyothi Kashi Nanjundasetty1, Mythri Halappa2, Vaddi Hari Krishna1
1 Department of Conservative Dentistry and Endodontics, Sree Siddhartha Dental College and Hospital, Tumkur, Karnataka, India
2 Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Tumkur, Karnataka, India
|Date of Web Publication||28-Feb-2014|
Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Tumkur - 527 107, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: With the whole world looking at the eradication of existing infectious diseases and preventing any new infections, sterilization of instruments is significant to ensure optimal patient care. Infection preventions and controls are the most important components for providing a safe environment for patients and staff within a dental practice. Hence, the objective was to assess the level of knowledge, attitudes, and practices regarding the sterilization of endodontic files by the postgraduate (PG) students from the Department of Conservative Dentistry and Endodontics at dental colleges in Bangalore. Materials and Methods: A cross-sectional study was conducted among PG students of Conservative and Endodontics in Bangalore using a pretested questionnaire. Results: A total of 88% accepted endodontic files need to be sterilized and 60% reported that endodontic instruments can be used four or more times, but 44% practiced it. Interestingly, 74% reported that dental assistants are not trained for sterilization protocols. Conclusion : The study shows that although there is high knowledge and positive attitude regarding sterilization of endodontic files, but it is seldom practiced creating lacunae in motivation. To bridge this gap, frequent reinforcement is needed in the critical area of sterilization.
Keywords: Endodontic, endodontic files, infection control, post graduate, sterilization
|How to cite this article:|
Aslam A, Panuganti V, Nanjundasetty JK, Halappa M, Krishna VH. Knowledge and attitude of endodontic postgraduate students toward sterilization of endodontic files: A cross-sectional study. Saudi Endod J 2014;4:18-22
|How to cite this URL:|
Aslam A, Panuganti V, Nanjundasetty JK, Halappa M, Krishna VH. Knowledge and attitude of endodontic postgraduate students toward sterilization of endodontic files: A cross-sectional study. Saudi Endod J [serial online] 2014 [cited 2020 Jan 25];4:18-22. Available from: http://www.saudiendodj.com/text.asp?2014/4/1/18/127982
| Introduction|| |
Infection control procedures are essential to modern dentistry and have an impact on all clinical practices.  They are the most important components for providing a safe environment for patients and staff within a dental practice.  Instruments that contact vital areas of the body, enter the vascular system or penetrate the oral mucosa are classified as 'critical items' and must be sterile before use. The classification includes endodontic files; thus, these instruments should be sterile before use and reuse. 
In the absence of adequate infection control procedures, there is a realistic potential to transmit pathogenic microbes via endodontic instruments. These pathogenic microbes may be sourced from within the root canal or from the periradicular tissues. During the cleaning and shaping of the root canal, residual organic and inorganic material accumulates on the working sections of files from one patient to another is substantial because they can act as antigens, infectious agents, or nonspecific irritants. 
The complex, miniature architecture of endodontic files makes the precleaning and sterilization difficult. Devising a sterilization protocol for endodontic files requires care. 
Sterilization plays a very important role in the prevention of cross infection.  There is general agreement that the presence of debris may interfere with sterilization by forming a protective barrier that prevents the complete sterilization of the surface beneath. Hence, if bioburden is not removed then any sterilization procedure may be futile.  The risk of infection is greater for the endodontist and his staff than for the patients.
The cleaning of instruments to remove microorganisms and biological debris effectively eliminates the majority of microorganisms.  As endodontic files have no internal surfaces that cannot be reached, it would be expected that a cleaning protocol could be developed that results in files free of bioburden. ,
Furthermore, files which may carry significant material residues after washing might pose a threat of transmission risks if this residue were to carry variant Creutzfeldt-Jakob disease More Details (vCJD) infectivity as it is an incurable, fatal disease and the causative agent, an abnormal prion protein is resistant to conventional sterilization procedures. 
Considering the enormity of the challenge that infectious agents pose the implementation of effective sterilization protocol among all healthcare communities including dental office is vital. Among the healthcare workers, dentists have a critical role to play in prevention efforts and they are an important population to study their level of knowledge, attitudes, and behavior regarding disinfection. 
Being the pioneer of dentistry in India, Karnataka has 43 dental colleges,  among that 18 colleges are situated in Bangalore city  making it a dental hub. Out of 18 colleges, 15 colleges offer postgraduation in Conservative Dentistry and Endodontics. Hence, the purpose of the present study is to delineate the level of knowledge, attitudes, and practices regarding the sterilization of endodontic files among postgraduate (PG) students of Conservative Dentistry and Endodontics from dental colleges of Bangalore.
| Materials and Methods|| |
A cross-sectional study was performed in the geographic area of Bangalore. All the PGs (I, II, and III year) from Department of Conservative Dentistry and Endodontics in Bangalore dental colleges (present on the day of survey) were included in the study.
Verbal consent to participate in the study were obtained from all the PG's after informing about the research context by a trained informer prior interview and no personal information were gathered.
Face-to-face interview was conducted and the data collected were entered in a prescribed format. Privacy was guaranteed and the individual results were kept confidential.
The questionnaire was designed such that it is divided into sections:
- Knowledge about standard sterilization protocols of endodontic files
- Attitude towards the utility of guidelines/protocols perception of sterilization in the success of root canal treatment
- How these sterilization protocols are precisely practiced.
Majority of the questions were close ended. The feasibility of the study and the clarity, quality, and length of the questionnaire items were ensured by means of pilot survey conducted in Department of Conservative Dentistry and Endodontics at Sri Siddhartha Dental College, Tumkur. Ethical clearance from Sri Siddhartha Dental College was obtained. The data obtained was subjected for statistical analysis. Descriptive analysis with Chi-square test was used to compare knowledge and practice. P value less than 0.05 was considered as statistically significant.
| Results|| |
Overall, 92 students participated in the study, among which 64% were females. In knowledge section, 88% accepted endodontic files need to be sterilized and 60% reported that endodontic instruments can be used four or more times. To clean the endodontic files, they reported ultrasonic bath (40%), brushing with soap (30%), any other (23%), and chemical solutions (7%). For sterilization, 48% said autoclave and 43% glass bead sterilization. All of the PG students (99%) perceived that cross infection can occur with the use of unsterilized endodontic rotary files and all of them considered importance of sterilization to prevent it. A 66% of the participants believed that sterilizing instruments will not consume much time. Interestingly, 74% reported that dental assistants are not trained for sterilization protocols and 15% with no dental assistants itself.
In practice, 44% used same endodontic files for four or more times and 46% used three times per day; whereas, 36% reported that two sets of files were used per day. Even though majority perceived the importance of sterilization, 60% said they will not sterilize new endodontic files before use and 19% before reuse.
In practice, the method of cleaning was brushing with soap (40%), ultrasonic bath (29%), and chemical solution (7%). This difference in knowledge and practice is statistically significant [Table 1].
In addition, 61% reported using autoclave and 32% glass bead sterilizer for sterilizing endodontic instruments. This difference observed between knowledge and practice is statistically highly significant [Table 2]. P value less than 0.05 was considered statistically significant.
|Table 2: Comparison of knowledge and practice for method of sterilization |
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| Discussion|| |
The emergence of the blood-borne pathogens and the infections are of increasing interest in dental healthcare which compel the dental professionals to have thorough knowledge about contagious diseases and its management. This survey yielded interesting findings regarding knowledge, attitudes, and practice among PGs of endodontics.
The data from this study indicated that the current state of student's knowledge related to sterilization of endodontic files was high. As cleaning and sterilizing endodontic instruments is a prerequisite for their reuse, knowledge regarding single use endodontic files was only known by 20%. This was similar to the Parashos study where cleaning protocol suggested does not support the recommendation of the single use endodontic files.  Instrument sterilization involves four distinct processes; presterilization, cleaning, sterilization, and aseptic storage. The methods for decontaminating endodontic instruments that are routinely applied are ineffective in removing biological debris.  The importance of cleaning the instruments before, during, and after the use is mentioned in many studies. ,,, Many methods have been advocated for cleaning; cotton rolls, gauze, sponges, hand brushes, rubber dam, clean-stand, and ultrasonic cleaner where some of them are used dry or soaked with disinfecting or antiseptic substances.  Before and after use, the two most popular means for cleaning the instruments are manual scrubbing with brush and ultrasonic cleaning.  The present study showed that ultrasonic bath was the most common known method of choice to clean the endodontic files. Similarly, ultrasonic bath method was observed as best method to clean endodontic files in a study after evaluating biological debris,  and microbial counts;  and in a study where stainless steel and nickel-titanium files were compared for sterilization procedures. 
Ultrasonic cleaners have the advantage of being faster, easier in cleaning besides reduces the direct handling of contaminated instruments which decreases the chances of accidental skin punctures and cuts from pointed or sharp instruments.  The optimum time for cleaning is between 5 and 10 min. 
Dentists often clean the metal shaft of files and forget the plastic handles. This portion of the files also must receive a considerable amount of attention due to the possibility of cross-contamination.  Autoclave is the first method of choice followed by dry heat, chemical vapor for critical and semi-critical instruments.  The glass bead sterilizer used as an aid for a chairside fast sterilizer  may be effective sterilizing the working ends, but ineffective in completely sterilizing.  It depends upon an improved temperature controlling system.  In the present study, participants considered autoclave and glass bead (type of dry heat) sterilizer as method of choice. This finding was similar when the ability to sterilize endodontic files inserted into artificial sponges was tested,  and in a microbial response using spore strip in selected endodontic offices.  Complete sterilization is possible by autoclaving endodontic box. This is significantly similar to the findings by Venkatasubramanian et al.,  Rajkumar et al.,  Hurtt et al.,  and Velez et al.  A study conducted to test the sterility of new unused endodontic files received by manufacturers also indicated that they should be sterilized before use  and sterility was ensured only after autoclaving. 
Along with the knowledge regarding sterilization of endodontic files, 99% perceived its importance in inhibiting cross infection indicating high positive attitude. A similar result was observed in nurses of Italy regarding the guidelines for disinfection and sterilization practice.  The remaining 1% did not know that endodontic instruments do cause infection and this is similar to the Turkish dentists where both knowledge and attitude was low regarding cross infection control.  About 15% of the PG reported that the absence of dental assistants and inadequate training for assisting personals indicating lacunae in the knowledge and importance of training. This is similar to the survey on nurses of Italy where the knowledge on hospital-acquired infections (HAIs) was not satisfactory making them not to perform appropriately the disinfection in their work activity. 
In practice, the present study showed 90% used same endodontic files three or more times per day, this may be due to time constraint, financial barrier to use new set for each patient. Hence, even though majority perceived the importance of sterilization, 60% said they will not sterilize new endodontic files before use and 19% will not sterilize before reusing them. This is similar to Askarian et al., who stated in their study a poor adherence to standard sterilization procedures among dental healthcare professionals in Shiraz.  The literature knowledge emphasize that only having knowledge of infection control measures and a positive attitude towards them does not ensure adherence to the guidelines.  Similarly, in our study we found that although knowledge and attitude towards sterilizing endodontic instruments is high, practice is not coherent with the literature knowledge. The difference obtained regarding knowledge and practice of cleaning and sterilization of the endodontic files is statistically significant. Hence, the findings of the present study marked the importance of training the students and maintaining strict protocol regarding sterilization of endodontic instruments.
The present study showed that the PG students learnt infection control measures from faculty lessons showing increased knowledge, but the practice in the clinical environment reviewing the guidelines should be emphasized. One should abide themselves to the universal guidelines like "Standard infection control and precautions",  "American Dental Association Recommendations", and guidelines set by Center for Disease Control and Prevention. ,,,,,,,,
In addition, by involving the dental assistants in the training programs, we can raise their sensibility regarding the importance of the sterilization of endodontic files along with other instruments. To address these shortfalls and to improve the adherence to procedures, constant motivation is required. Improved compliance with recommended infection control measures is required for all dental healthcare personnel's. Continuing dental education programs and short-time training courses about cross infection and infection control procedures are suitable for dental students, dentists, and dental assistants to upgrade as well as to reinforce the practices.
| Conclusion|| |
The study revealed high level of knowledge and extremely positive attitude towards the utility of guidelines and protocols for sterilizing endodontic files.
Contrary to knowledge and attitude, practice is not coherent with sterilizing endodontic files.
The difference obtained regarding knowledge, attitude, and practice of cleaning and sterilization of the endodontic files is statistically significant.
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[Table 1], [Table 2]