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ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 155-160

Knowledge regarding technical aspects of non-surgical root canal treatment in Al-Madinah Al-Munawarah private dental centers


1 Department of Restorative Dental Science, College of Dentistry, Taibah University, Medina, Saudi Arabia
2 Department of Preventive and Dental Public Health, College of Dentistry, Taibah University, Medina, Saudi Arabia

Date of Web Publication26-Aug-2015

Correspondence Address:
Mothanna Alrahabi
Department of Restorative Dental Science, College of Dentistry, Taibah University, Medina
Saudi Arabia
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Source of Support: Nil., Conflict of Interest: None


DOI: 10.4103/1658-5984.163625

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  Abstract 


Objective: We evaluated knowledge of technical aspects of non-surgical root canal treatment among general dentists in private dental clinics in Al-Madinah Al-Munawarah, Saudi Arabia. Materials and Methods: A questionnaire was distributed randomly to 70 general dental practitioners who were working in private dental centers. The response rate was 88.6%. Results: The results showed that only 3% of dentists were using rubber dams for isolation during endodontic treatment. The majority (59.7%) were using radiographs to determine the length. Also, 37% were using nickel-titanium (NiTi) rotary instruments to prepare the root canal. The lateral condensation technique with gutta percha points to fill the root canal was used by most respondents (77.5%).
Conclusions: This study provides important data on endodontic treatment by general dental practitioners in Al-Madinah Al-Munawarah private dental centers. It shows a general lack of knowledge regarding the importance of using rubber dams as well as the new endodontic materials and methods. Continuing education programs to update their knowledge in the field of endodontics are essential.

Keywords: Al-Madinah Al-Munawarah, endodontic treatment, general practitioner, private dental centers, Saudi Arabia, technical aspects


How to cite this article:
Alrahabi M, Ahmad MS. Knowledge regarding technical aspects of non-surgical root canal treatment in Al-Madinah Al-Munawarah private dental centers. Saudi Endod J 2015;5:155-60

How to cite this URL:
Alrahabi M, Ahmad MS. Knowledge regarding technical aspects of non-surgical root canal treatment in Al-Madinah Al-Munawarah private dental centers. Saudi Endod J [serial online] 2015 [cited 2020 Sep 29];5:155-60. Available from: http://www.saudiendodj.com/text.asp?2015/5/3/155/163625




  Introduction Top


Root canal treatment is one of the essential dental services provided to the population in developed countries. The American and European clinical endodontic guide provides step-by-step treatment guidelines for both endodontists and general practitioners (GPs).[1],[2] However, several studies have reported that most GPs do not adhere to these guidelines.[3],[4] Dummer[5] assessed the radiographic images of root canal fillings performed by GPs. He found that only 10% of the treated cases fulfilled the technical criteria for the standard of care, as defined by the European Society of Endodontology.[1]

Various investigations have been carried out to explore the standard of root canal therapy by GPs.[2],[6],[7],[8] The failure rates of endodontic treatment were found to be higher for teeth treated by non-endodontists.[9] The outcome of endodontic therapy has been associated with a variety of factors. The knowledge of general practitioners and endodontists regarding technical aspects of non-surgical endodontic treatment is one of these factors.[10]

In recent years, the practice of modern endodontics has been subject to several new technologies that can improve its efficiency, safety, and quality.[11] Several reports have shown that general practitioners tend to be slow to adopt new advances in endodontic technology, despite their effects on the quality and efficacy of root canal therapy.[12],[13]

Natto[8] reported a pilot study characterizing methods and practices used in root canal treatments by GPs in eight cities in Saudi Arabia, including Al-Madinah Al-Munawarah. He found the practice of endodontics by the GPs was not supported by scientific evidence. Unfortunately, the performance of the GPs in each city was not mentioned separately. Thus, the purpose of this study was to evaluate the knowledge of technical aspects of non-surgical root canal treatment performed by GPs working in private dental centers in Al-Madinah Al-Munawarah, Saudi Arabia.


  Materials and Methods Top


A self-administered questionnaire-based survey was developed and distributed randomly to 70 general dental practitioners working in private dental centers in Al-Madinah Al-Munawarah. It was collected after 1 week. The study was conducted between May and August 2013.

The questionnaire consisted of 15 questions dealing with technical aspects of non-surgical root canal treatments, as practiced by the GPs. To maintain confidentiality, dentists were instructed not to write their names on the questionnaire form. Dentists were asked to give more details regarding the given questions. The collected data were analyzed using the Statistical Package of Social Sciences (SPSS) software. Simple descriptive statistics were used, together with the χ2 test.


  Results Top


Results are summarized in [Table 1] and [Table 2]. In total, 62 (88.6%) completed questionnaires were received. Most respondents (51%) had more than 13 years of postgraduate professional experience as a dentist [Table 1]. About 52% did not take periapical radiographs for diagnosis before starting root canal treatment (RCT). Pulp tests were not performed by 71% of the GPs. Only 3% of the GPs were using rubber dams. Single-visit RCTs of vital cases were practiced by 50% of the GPs. The standardized technique (38.7%) and the use of nickel-titanium (NiTi) rotary instruments (37%) were most commonly used to prepare the root canal system. Sodium hypochlorite (NaOCl) (61.3%) was the irrigant of choice and calcium hydroxide (Ca(OH)2) was used by most of the GPs (67.8%) as an intracanal medicament. The percentage leaving the tooth open (37%) in cases of necrotic pulp was similar to that for closing with a cotton pellet and medicament [Table 2]. The most commonly used technique to fill the root canal system was lateral condensation (77.5%). No statistically significant difference was found between the GPs' professional experience and any of the materials, instruments, or techniques used (all P > 0.05).
Table 1: Experience of the general practitioners (GPs) and the average number of treated teeth

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Table 2: Performance of RCT by general practitioners (GPs)

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  Discussion Top


A survey questionnaire is a common method to evaluate healthcare systems, and to overcome the disadvantages of sending the questionnaire by post or email, the questionnaire was distributed to dentists individually then collected after meeting them.[14] This was reflected in the response rate (88.6%), which was higher than in previously published surveys in various countries.[4],[15]

We investigated the materials, methods, and technical aspects of non-surgical root canal treatment used by general practitioners working in Al-Madinah Al-Munawarah private dental care centers. The results of this study revealed a large gap between the theoretical knowledge of modern endodontics and real practice in these centers.

It is well-known that a preoperative radiograph must be examined and interpreted prior to treatment[1] as an essential element in diagnostic procedures in endodontics. This provides valuable information that can be compared with other diagnostic tests.[16],[17] The results of this study revealed that 48.4% of GPs took preoperative X-rays and 51.6% did not.

Pulp testing is an important aid in determining pulp vitality and provides valuable information to the dental clinician.[18] The percentage of practitioners using pulp tests in this study was only 29%. This may have been to save the time and money during non-surgical root canal treatments.

Using a rubber dam during non-surgical root canal treatment is essential and is the standard of care.[1],[19] However, only 3% of the GPs in this study used a rubber dam during root canal treatment. Similar findings were reported by Al-Fouzan[10] in non-Saudi GPs working in private practice in different cities in Saudi Arabia. This percentage was increased slightly, to 9%, in a recently reported study by Iqbal et al., in the north of Saudi Arabia. The findings of the current study differ from reports in the USA, in which 60% of GPs use rubber dams during root canal treatment.[20] The practitioners who did not use rubber dams justified this by the difficulty of applying a rubber dam, that it was time-consuming, and some patients refused it as main reasons. According to Al-Abdulwahhab et al.,[21] a newly graduated intern dentist in Saudi Arabia in likely to use a rubber dam for endodontic treatment whether in the posterior teeth (73.3%) or anterior teeth (68.7%). Attending continuing education courses will encourage GPs to use rubber dams.[22],[23]

Preparing the endodontic access cavity is a key step in root canal treatment in which the root canal entrances will be identified. Fissure carbide and diamond burs with safety tips (non-cutting ends) are safer choices for axial wall extension into the pulp chamber.[24] Although 32% of GPs in this study used Gates Glidden drills or ultrasound to enlarge orifices of the canal, only 10% of GPs used safety burs during cavity access. Using Gates Glidden drills for cervical flaring favors reliable working length determination[25] and apical gauging.[26],[27]

Different methods are used for working length determination. These include radiographs, electronic, and tactile methods.[28] Traditionally, the most common method for length measurement is radiographs. Electronic apex locators are a modern endodontics innovation and are more accurate in locating the minor apical foramen and measuring the working length than radiographs.[29],[30] In this survey, most of GPs (59.7%) preferred to determine working length with radiographs. Iqbal et al.,[23] reported an even higher percentage (86.5%) in the northern part of Saudi Arabia. Determination of the working length using radiographs can be affected by several obstacles, such as canal curvature, location of the apical foramen, and superimposition of anatomical structures.[28] GPs who did not use an apex locator explained about the high cost of apex locators and some were unfamiliar with apex locators because they were not included in the curriculum during their undergraduate studies.

Practicing single-visit endodontic therapy has many advantage. It reduces the number of visits and eliminates the chance for interappointment microbial contamination.[31],[32] In this study, more than 50% of GPs preferred to provide single-visit root canal treatment for vital cases. This findings contrasts with Al-Fouzan[10] who found that the majority of non-Saudi GPs did not practice single-visit root canal treatments. He attributed that to the undergraduate teaching of root canal treatments at different dental schools and the lack of modern endodontic equipment in their clinics. Although there are reports mentioning that there was no difference in success rate between single- and multiple-visit root canal treatment, they were in necrotic cases.[33],[34],[35]

Cleaning and shaping of the root canal system is the second important step after cavity access. The "standardized technique" is the oldest technique for root canal instrumentation and, to date, some practitioners still use it. In the current study, 38.7% of GPs used the standardized technique and 37% used NiTi rotary instrumentation. This percentage seems to be reasonable when compared with Iqbal et al.,[23] and other reports from different countries[12],[13],[36] and differs from the results of Al-Fouzan[10] who reported that 91% of non-Saudi GPs used the step-back preparation technique in four cities of Saudi Arabia. Additionally, Natto[8] reported 79% in eight cities in Saudi Arabia.

The instrument sequence in the standardized and step-back techniques starts from the apical end of the canal to the coronal part. Unfortunately, this instrumentation approach does not fulfill the objectives of shaping the root canal in curved root canals and can lead to iatrogenic damage to the original shape.[25] However, NiTi instruments have high flexibility to keep the original path of the canal[37] and reduce the incidence of several clinical problems, such as the formation of blockage or ledges, transportation, and perforation.[38]

The majority of GPs in the current study used NaOCl as the primary irrigant (61.3%). Similar findings were reported by Natto.[8] Saline was the most commonly employed by non-Saudi GPs in Al-Fouzan's[10] study. He related that to the low percentage of rubber dam use. Sodium hypochlorite is the recommended irrigating solution by most of those practicing root canal therapy. It has several advantages, such as tissue dissolution[39] and antimicrobial activity.[40]

A historical root canal treatment procedure is leaving necrotic teeth open between visits for drainage and managing intractable pain.[41],[42] This procedure is now considered unacceptable and can complicate root canal treatment because reinfection will likely occur.[43][44][45] In this study, 37% of the practitioners left the tooth open between visits. This is similar to the report of Savani et al.,[20] in the USA and higher than the findings of Natto.[8]

Calcium hydroxide is the recommended intracanal medicament for use in multiple-visit treatment.[46] In this study, most of the respondents used calcium hydroxide as an intracanal medicament (67.8%). This finding is consistent with Chan et al.[47] In the northern part of Saudi Arabia, the percentage of GPs that used Ca (OH) 2 as an intracanal medication was 15%.[23] Similar findings were reported by Natto.[8] He attributed that to the belief of the GPs of its weak effects, or to insufficient knowledge. Al-Fouzan[10] reported that the formocresol was the medicament routinely used by GPs. However, formocresol is now considered a mutagenic and carcinogenic agent that should not be used in modern endodontic treatment.[48]

Three-dimensional root canal obturation is a fundamental prerequisite to prevent reinfection of the root canal system.[49][50][51] The results of this survey showed that 77.5% of practitioners in our sample used the lateral condensation technique to fill the root canal. Similar findings were reported by Al-Fouzan,[10] Iqbal et al.,[23] and Natto.[8] Lateral condensation remains the most popular technique in root canal obturation and several reports have indicated that almost all dental schools in the US (>90%) teach only cold lateral compaction in their pre-doctoral programs.[52]


  Conclusions Top


This study provides important data on endodontic treatment by general dental practitioners in Al-Madinah Al-Munawarah private dental centers. Our findings suggest a general lack of knowledge regarding the importance of using rubber dams as well as new endodontic materials. A continuing education program to update their knowledge in the field of endodontics is essential.



 
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    Tables

  [Table 1], [Table 2]


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