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Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 1-7

What opinions do Saudi endodontic residents hold about regenerative endodontics?

1 Department of Restorative Dentistry, College of Dentistry, Al Jouf University, Sakakah, Kingdom of Saudi Arabia
2 Department of Restorative Dentistry, College of Dentistry, Al Jouf University, Sakakah, Kingdom of Saudi Arabia; Department of Restorative Dentistry, Azra Naheed Medical College, Superior University, Institute of Advanced Dental Sciences and Research, Lahore, Pakistan
3 Ministry of Health Dental Centre, Arar, Kingdom of Saudi Arabia

Date of Web Publication8-Jan-2019

Correspondence Address:
Dr. Salman Aziz
Azra Naheed Medical College, Superior University, Institute of Advanced Dental Sciences and Research, Lahore, Pakistan

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_103_17

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Aim: The aim of this study is to investigate the opinions, current knowledge, and expectations of Saudi endodontic residents regarding the use of regenerative endodontics as part of future dental treatment and establishing a baseline for further research and development.
Materials and Methods: Saudi endodontic residents all over Kingdom of Saudi Arabia (KSA) were contacted, for participation. A survey form consisting of 28 questions was personally distributed to all endodontic residents who were actively enrolled in a residency training program either Saudi board program or Master Degree and provided informed consent for inclusion into the study. Data were collected and statistical analysis was carried out using SPSS version 22.
Results: Out of one hundred and fifteen endodontic residents 97 participated in this questionnaire-based survey. Two forms were excluded due to incomplete and unclear information. Out of the remaining 95 majority of the residents were male (67.4%) and belonged to Saudi board program. The greater part of residents agreed for the inclusion of regenerative endodontics in the dental curricula. Most of the candidates wanted to improve their skills in regenerative endodontics by participating in continuing dental education programs. The most popular belief (n = 81) was that regenerative therapy to save teeth is better than implants. Use of regenerative procedures in clinics was carried out by only 44 participants.
Conclusion: The emerging importance of regenerative endodontics in KSA is evident through this study. This study highlights many core issues which need attention and forms a baseline for further research in regenerative endodontics.

Keywords: Continuing dental education, endodontic residents, regenerative endodontics

How to cite this article:
Al Qahtani SS, Aziz S, Al Garni H, Alaenazi MS. What opinions do Saudi endodontic residents hold about regenerative endodontics?. Saudi Endod J 2019;9:1-7

How to cite this URL:
Al Qahtani SS, Aziz S, Al Garni H, Alaenazi MS. What opinions do Saudi endodontic residents hold about regenerative endodontics?. Saudi Endod J [serial online] 2019 [cited 2020 Aug 8];9:1-7. Available from: http://www.saudiendodj.com/text.asp?2019/9/1/1/249589

  Introduction Top

Transplants utilizing cord banking have been carried out in the Kingdom of Saudi Arabia (KSA) ever since 2003 at King Faisal Specialist Hospital and Research Centre in Riyadh. It was the pioneer of cord banking in the KSA and to date stores more than 4600 units of cord banks. Saudi Arabia's second cord bank has been functioning at King Abdullah International medical research center managed by National Guard Health Affairs since 2011. This bank stores over 2000 cord bank units. National Guards Health Affairs also established the first stem cell donor registry in KSA.[1] Therefore, the field of stem cell and cord banking seems to be fairly established in KSA and these points to the prediction that the field of dental stem cell therapy in the Kingdom holds a promising future. The upcoming age of dentistry is thought to hold extraordinary advances, especially in the ever-evolving field of endodontics.[2],[3] The emerging subspecialty of endodontics which relates to rejuvenation of diseased or dead pulpal tissue to restore the lost functionality has been referred to as “regenerative endodontics.”[4] Pulpal regeneration is “in” these days. It is the new future of endodontics. The temptation of regenerative endodontics is such that both clinical and academic specialists are speculating, it would replace the current conventional endodontic procedures and techniques.[5]

Evidence demonstrates the possibility for regeneration of pulp tissue within the root canals and continued the development of roots in teeth with pulpal necrosis and closure of the apices.[6],[7],[8],[9],[10],[11] The procedures that lead to pulpal regeneration are divided into three main categories, namely, revascularization of blood clot, implantation of tissue-engineered dental pulp constructs into the disease affected site, and incorporation of stem cells into the diseased pulp. The feasibility and success of revascularization procedures in endodontics is supported by recent literature in the form of case reports as well.[7],[8],[9],[10],[11] The publications advocating the success of revascularization therapy have low sample size though; therefore, it will require quite a considerable amount of time to provide the readers with an evidence-based report of the highest grade. Moreover, major portion of regenerative procedures and experiments have been carried out in vitro. It is thus high time for transition of this novel therapy from laboratories to the clinics. However, to produce high-quality research, collaboration of basic scientists and clinicians would be an important prerequisite.[4] In this context, one of the main concerns is the acclimatization of our clinicians to the emerging novel therapies in endodontics. To provide the patients with best treatment options, dentists should be familiar with the latest breakthroughs for they are the ones to advocate evidence-based knowledge in day-to-day practice.

Utility of regenerative techniques in endodontics is becoming a popular treatment option and these points to the fact that endodontists in the making must have a clear understanding regarding the latest advances in regenerative dentistry.

There are two main postgraduate programs in endodontics in KSA, namely, Saudi Board also known as Saudi Specialty Certificate in Endodontics (SSC-Dent [Endo]) and Masters in Endodontics. These programs are recognized by Saudi Council for Health Specialties. SSC-Dent (Endo) as compared to masters is regarded as the highest exit specialty qualification in KSA and is therefore extremely competitive with examination structure comparative to the American Board of Endodontics; however, the clinical requirements of SSC-Dent (Endo) are much higher than American board of endodontics which makes it considerably more thorough clinically.[12]

It is of utmost importance to have an insight into whether postgraduate endodontic residents/students are aware of, or are practicing endodontic regenerative techniques, as till date there is no documented contribution to literature pertaining to the subject examined in KSA. The aim of this study was therefore to determine the opinions, current knowledge, and expectations of Saudi endodontic residents regarding regenerative endodontic procedures as part of the future dental treatment. Furthermore, this study would also help in establishing a baseline for further research and development regarding “Regenerative Endodontics” in the Kingdom.

  Materials and Methods Top

The study was approved by the Institutional Ethics Review Board of Al Jouf University College of Dentistry Saudi Arabia (Ethical approval request no. 25/2/15/67). This survey was carried out all over KSA and involved all endodontic residents, who were enrolled in an endodontic program either masters or Saudi Board. Participants from both genders, attending the endodontic program recognized by the Saudi Commission for health specialties, were included in this study. The participants who met the inclusion criteria were asked for consent. Individuals who were not active in residency or did not consent to participate were excluded from this study. Moreover, survey forms with incomplete and unclear information were excluded. The self-explanatory questionnaire consisting of 28 questions was divided into three parts to assess the follows aspects:

  1. Professional status
  2. Ethical beliefs, judgment
  3. Clinical practice.

The survey was adapted from the publication titled “A practitioner survey of opinions toward regenerative endodontics.”[13] The form was reproduced after kind approval and consent of the corresponding author. The forms were provided in person to the residents and were retrieved as soon as they were completed. All personal information provided was kept confidential.

The details of questions asked are shown in [Table 1], [Table 2], [Table 3]. Data were entered into IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp Armonk, NY), and descriptive statistics were carried out.
Table 1: Professional status of endodontic residents

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Table 2: Ethical opinions, beliefs, and judgments of Saudi endodontic residents

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Table 3: Clinical practices of Saudi endodontic residents regarding regenerative endodontics

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  Results Top

Out of the postgraduate residents in the field of endodontics contacted all over KSA, 97 provided informed consent to participate in this questionnaire-based study.

Professional status

Majority of the participants comprised of Saudi board residents (n = 76) [Table 1]. More than half of the residents had prior knowledge regarding regenerative dental treatment through continuing dental education (CDE) (n = 59) [Table 1].

Ethical opinions, beliefs, and judgment

A vast majority of the residents agreed that regenerative therapy and stem cell banking will be useful for regeneration of damaged dental tissues. The high cost of treatment was seen as the biggest hindrance in acceptance of the regenerative treatment by most of the participants (n = 49). Majority of the participants believed that regeneration is a better option than implant (n = 81). Almost all of the participants agreed that animal trials must precede any sort of regenerative treatment before acceptance for human use [Table 2].

Clinical practices

The use of regenerative procedures in clinical practice was seen to be carried out by less than half of the candidates (n = 44), and their success was expressed by 49.5% of the individuals. Regarding the cost of regenerative dental treatment, 40% of the residents were in the favor of a higher cost as compared to the current treatment cost [Table 3].

  Discussion Top

To the best of our knowledge, this is the first study exploring the interests, knowledge, and attitudes of any group of Saudi residents regarding regenerative endodontics and its future in KSA. The current survey was based on Epelman et al. study,[13] who explored the perceptions of only endodontic practitioners of whom 56% participated. On the other hand, the survey in current study was targeted at the endodontic residents, and more than 80% of the postgraduates who were contacted took part in this questionnaire-based survey. The participants represented all the regions of KSA including the major cities such as Dammam, Riyadh, Jeddah, Makkah, Medina, Hail, and Abha. Majority of the participants belonged to Saudi board and were males. This finding of our study is somewhat contradictory to the findings of Al-Dlaigan et al.'s study where an overall higher trend for postgraduate training was noted among female dental graduates of King Saud University in Saudi Arabia.[14] In our opinion, the low female-to-male student ratio in postgraduate endodontic programs in Saudi Arabia could be because the female candidates started joining the Saudi board in the recent past.

The overall participation of candidates in the survey depicts the importance of regeneration in general and to the enthusiasm of the candidates in specific to this emerging treatment option in endodontics.

Majority of the participants recommended that regenerative endodontics must be a part of the dental curriculum and these points to need for appropriate changes in dental curricula accordingly. More than three-quarters of the residents showed interest in attending hands-on CDE on regenerative endodontics to improve their skills. These findings are in agreement to Basson et al.'s dentist directed survey conducted in South Africa where majority of the dentists highlighted the willingness to attend improvement courses for regenerative endodontics and also recommended the incorporation of regenerative endodontic procedures in dental curricula.[15]

It should be appreciated that most of the residents want to progress and learn new technologies and techniques and highlights the need for more comprehensive hands-on training workshops. Moreover, this confirms the awareness of Saudi Dental Society, Saudi Endodontic Society, and Saudi Council of Health Specialties toward regenerative endodontics in that they have made available the resources for the trainees to have the opportunity to explore the latest trends in endodontics, which is highly commendable.[16]

More than half of the participants of our study perceived that the greatest impediment on the route to patient's acceptance of stem cell therapy in dentistry will be high cost which is in accordance to the opinion given by endodontic practitioners in Epelman's study.[13] Furthermore, almost all of the participants were inclined to saving dental tissues and teeth for prospective use in regenerative treatment. This is really interesting to know that our residents are well aware of the importance of dental tissues and their role in regeneration. There was, however, apprehension regarding the implementation of regeneration therapy arising from stem cells and allogeneic tissues in KSA because it has been in the recent past that organ donation was approved as a treatment option.[17]

Implants use is rising in the kingdom and how regenerative endodontic treatment will compete is another question that remains unanswered. This is because there are many obstacles on the route to regeneration and the most important is the thought process of us dentists in general and specialists in specific. Everyone wants to grow back the natural body part if given a choice. Implants although successful are not equivalent to the natural tooth. Moreover, implant companies are promoting alternatives to natural structures through biased research,[18] we recommend to the reader to critically evaluate the results of implant success and survival before believing the conclusions of implant studies. Regeneration, on the other hand, does not offer any lucrative option to the implant or dental supply companies, therefore, we must protect the public interest by promoting what is ethical and try to save the tooth or revive the dying pulp as much as humanly possible before sentencing in favor of implants.

Majority of the participants of this study voted in favor of regeneration whereas only half of the participants of Utneja and Epelman's study agreed in opposition of implants.[3],[13] In contrast to Epelman et al.[13] study, we removed the option of unsure from the question regarding implants versus regeneration in our study [Table 2] as we believe that the knowledgeable residents are unlikely to be unsure and we wanted to have a clear vote in favor or against regenerative treatment. Moreover, we are of the opinion that the option of unsure given in Epelman et al.[13] study in this question complicates the results by putting in the factor of confusion. However, we recommend that such a study be carried out involving prosthodontic and maxillofacial residents whose opinion on this aspect is also very important.

A little more than half of residents did not incorporate regenerative endodontic procedures into practice [Table 3], and this finding is similar to the results of Basson et al.[15] and Manguno et al.,[19] where only a minority of the private practitioners and dental residents were using regenerative procedures in clinics, respectively. In response to possibility of enhancement of periapical healing by tissue engineering procedures, the residents gave a mixed response with a majority saying that they do not have adequate knowledge into this matter. However, the findings of Manguno et al.[19] were contrary to our study where majority of the residents were of the opinion that tissue engineering techniques will enhance periapical healing. The response of residents in our study could be due to the limitation of availability of suitable materials or due to the lack of appropriate training pertaining to regenerative endodontics. To build the confidence of our residents regarding regenerative procedures, it is recommended that hands on activities must be arranged, and to enable adequate regenerative practices the endodontic armamentarium be kept up to date. Sede et al.[20] in a cross-sectional study involving dental students also put forwards a similar recommendation.

A wide majority of respondents did not encounter necrotic immature teeth and avulsed teeth in practice. This could be because majority of cases of immature teeth belong to children aged <12 years and therefore seek pediatric dentist's care. This is another major area of concern. The endodontic residents must get some part of their residency training in pediatric dental clinics to enhance knowledge and expertise regarding the treatment of immature teeth with or without traumatic injuries.

Theoretical knowledge regarding the optimal methods of management of immature teeth of the respondents, on the contrary, seemed to be in accordance with the current literature.[21] Open apex poses the most challenging situation to the endodontists. Moreover, it is in this situation; we need regeneration the most. We believe that the option given by our residents were quite convincing and evidence-based as compared to Utneja and Epelman's study participants.[3],[13] The current evidence regarding placement of intracanal medicaments before regenerative process depicts mixed opinions. Some research is inclined toward the use of tri-antibiotic paste while some shows equality regarding cytotoxic effects of both tri-antibiotic paste and calcium hydroxide, but still most of the evidence states that calcium hydroxide causes impediment in regeneration process; therefore, it is still rarely recommended in cases suitable for regeneration.[22]

Mineral trioxide aggregate (MTA) on the other hand does not pose any such hindrance in the rejuvenation process, so most of the authors are in favor of its use.[23]

Cost of any dental treatment has an impact on treatment option selection by the patient. However, the best treatment comes at an added cost. In the opinion of majority of our prospective consultants, the cost of regenerative treatment should be higher than the cost of current treatment and this finding is in accordance with Manguno et al. study.[19] This could be because the residents have the firsthand experience in dealing with patients requiring regeneration and they are well aware that the amount of time, cost, and energy required for such procedures is more than that of conventional treatment. On the other hand, residents in Manguno et al.'s study agreed to provide regenerative treatment regardless of increase in monetary benefit; however, they proposed that patients should pay a yearly fee for maintaining their cells in the stem cell bank.[19]

When the participants were asked about what would compel them to recommend regenerative treatment for their patients, majority of them selected “if regenerative treatment is found to be the most effective treatment modality”. This draws attention towards the most important aspect of evidence-based treatment planning, which in turn points to the current lack of concrete evidence regarding efficacy of procedures. Although most of the endodontists are incorporating regenerative treatment options in their daily practices, it may take considerable time to evaluate and comment on the true effectiveness of each procedure, so as to make the specialists and postgraduate residents, comfortable with integrating regeneration into their treatment armamentarium to provide evidence-based information to patients in order for them to give informed consent. For this reason, more and more research is required in the field of endodontic regeneration.

Therefore, we recommend that further studies be carried out to enlighten the advent of regenerative endodontics in KSA and to explore and clarify the doubts and myths regarding regeneration in this part of the world.

  Conclusion Top

Our study points to the emerging importance of regenerative endodontics in KSA. This was a baseline survey that provided us with the basic mindset of our endodontic residents regarding their current regenerative procedures and practices. The current study also gives an insight into the preparedness of Saudi residents for the future of regenerative endodontic practices in Saudi Arabia. Although it might take a considerable amount of time for translation of stem cell therapy to dental clinical practice, many regenerative techniques in one form or another are being practiced in KSA. There is still need for more in vitro and in vivo research in the evolving field of regenerative endodontics.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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