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Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 101-108

Impact of educational background on knowledge, attitude, and practice of root canal treatment among male university and high school students of Sakaka Province

1 Department of Conservative Dentistry, College of Dentistry, Jouf University, Aljouf, KSA
2 Department of Orthodontic, College of Dentistry, Jouf University, Aljouf, KSA

Date of Web Publication3-Apr-2019

Correspondence Address:
Dr. Ravi Jothish
Department of Conservative Dentistry, Endodontics Section, College of Dentistry, Jouf University, P. O. Box-2232, Sakaka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_78_18

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Aim: To determine the knowledge, attitude, and practice of root canal treatment (RCT) among male university and high school students of Sakaka province and to compare and analyze the impact of educational status on the three parameters mentioned earlier.
Materials and Methods: A self-administered questionnaire prepared in Arabic and English was circulated among 600 male participants who consented to participate in the survey. Participants were divided into two groups – Group 1 (University) and Group 2 (high school) students. Pearson Chi-square test was used to analyze the data.
Results: Data sheets were received from 500 participants only. Most of the participants, irrespective of the group, visit dentists only on the appearance of pain (84% and 82.8%, respectively). Substantial number of participants had a history of RCT (24.7% and 42.2%, respectively); 8.7 and 17% from respective groups reported that they were uncomfortable during the past RCT. However, majority of the participants (64.7% from either group) mentioned that they would opt for RCT in the future despite the slightly negative experience of the past.
Conclusion: Young adults are reasonably well informed about RCT. Exposure to alternative sources like social media seems to be the reason behind this. Hence, internet platforms should be used to further popularize RCT among the youth.

Keywords: Attitude, knowledge, practice, root canal treatment, Sakaka Province

How to cite this article:
Jothish R, Alam MK, Alam F. Impact of educational background on knowledge, attitude, and practice of root canal treatment among male university and high school students of Sakaka Province. Saudi Endod J 2019;9:101-8

How to cite this URL:
Jothish R, Alam MK, Alam F. Impact of educational background on knowledge, attitude, and practice of root canal treatment among male university and high school students of Sakaka Province. Saudi Endod J [serial online] 2019 [cited 2020 Sep 26];9:101-8. Available from: http://www.saudiendodj.com/text.asp?2019/9/2/101/255370

  Introduction Top

Tooth loss was widely acceptable and considered a natural consequence of aging almost throughout the last century. However, everything changed with the World Health Organization (WHO) report of 1979, which for the first time, considered oral diseases culminating in tooth loss as a serious public health problem. An international resolution was passed to gradually get the decayed-missing-filled teeth (DMFT) index at the age of 12 years to be reduced to 3 by the year 2000. As a part of that mission, a global campaign with equal emphasis on primary, secondary, and tertiary prevention strategies was launched. Root canal treatment (RCT), as a tertiary preventive method, has succeeded in saving millions of teeth ever since.[1] RCT is indicated when the pulp becomes irreversibly inflamed or infected. Usually, the cause for inflammation or infection is a deep cavity, trauma to the tooth, or extensive restorative treatment. The signs of pulpal damage include pain, thermal sensitivity, color changes, and swelling or soreness in the gums. Once the pulp becomes inflamed or infected, RCT or extraction is necessary to remove the affected tissue and restore the area back to health. Since its inception, science of endodontics has become very predictable and successful as evident from the prognosis that is often quoted as high as 95%.[2] Hence, as long as it is restorable, RCT should be the first choice to save a bad tooth, but unfortunately that is often not the case.

As a profession, endodontics is largely evidence based as it should be but several nonclinical factors influence patient's treatment decision. Some of the factors examined in the past studies include patient's socioeconomic status, level of education, perspective about quality of life and health, expectations, and objective or subjective past dental experiences.[3] Some of these factors as well as misconceptions about the procedure are often cited as reasons for people opting out of RCT. Thus, these factors dictate the opportunities availed by the patients and also the challenges faced by the clinician as he works hard at convincing patients about the benefits of the treatment. Patient's education status, level of awareness, and general attitude toward health and hygiene play crucial role in overcoming these hurdles and seeking timely treatment for his problems. Today, most patients are expected to be well informed and aware of the opportunity provided by endodontics so that they take treatment decisions considering the risk–benefit ratio.[4]

There have been several studies in the past surveying the knowledge, attitude, and practice of root canal among different populations.[3],[5],[6] The findings of most of these studies agree with each other and reinforce the fact that certain patterns prevail in the oral health-care systems globally. To the best of our knowledge, no study of this sort has been done in the Sakaka Province of Al-Jouf area, Saudi Arabia. One-fifth of the world population is adolescent defined by the WHO as a person between 10 and 19 years of age. They are highly ambitious, well-informed people with high self-esteem, but it has been found that parents, siblings, peers, and even celebrities have tremendous impact on how they think and behave. When they have access to quality information, they have been found to take positive decisions on health.[7] This prompted us to conduct a survey on the prevailing situation among two adolescent subpopulations of Sakaka Province. Hence, the prime objective is to determine the knowledge, attitude, and practice of RCT among medical male University and high school students and then to compare the two and determine the impact of educational status on the above-mentioned parameters.

  Materials and Methods Top

Detailed research proposal along with the questionnaire (in both Arabic and English) to be used for the survey were submitted to Local Committee of Bioethics (LCBE) of Al-Jouf University. All the supporting documents including forms to obtain informed consent and parental consent (for participants below the legal age) were furnished as per the recommendations of LCBE. Researchers confirmed that they would be complying with the Helsinki Declaration during the course of the study. After getting the approval of the LCBE (Approval no. 8-16-8/39), permission was obtained from the institutional heads to conduct the survey in their premises. Medical college campus, Al Jouf University was selected for the age group 18–19 years (Group 1) and the local high school for the age group 16–17 years (Group 2).

Inclusion criteria

  1. Participants of legal age group who volunteer after the principal investigator explain the study to them
  2. Participants under the legal age who obtained written parental consent.

Exclusion criteria

  1. Participants who declined to participate
  2. Participants who did not obtain the mandatory written parental consent.

Our statistician had suggested a sample size of 600. Hence, the questionnaire [Appendix 1] was distributed among 600 participants. Part 1 was designed to collect some personal details after assuring confidentiality. Part 2 had seven questions about the participant's awareness about RCT and only participants with the past RCT were eligible for part 3. Even though it was meant to be self-administered, members of the research group were readily available to the participants for any assistance. Completed data sheets could be obtained only from 500 participants; this data collected was then fed into Excel sheets and statistically analyzed using the IBM SPSS Statistics Version 20.0 (Chicago, IL, USA) with confidence level set at 5% to test for any significance. P < 0.05 was considered as statistically significant.

  Results Top

Of the 500 students who completed the survey, 30% were in Group 1 and 70% were in Group 2. An overwhelming majority, 84% of Group 1 and 82.8% of Group 2 revealed that they visit dentist only after the appearance of pain. 10% and 10.9%, respectively, sought the dentist's help to improve their appearance. Only 6% and 6.3% from the respective groups went for regular periodic checkup [Figure 1].
Figure 1: Reasons for visiting the dentist across the two groups. Pain (1), improve appearance (2), and regular maintenance (3). Med: Medical student and HS: High school student

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Nearly 48.7% of Group 1 and 59.5% of Group 2 knew about RCT. Significant difference was found between the two groups (P < 0.01). The main source of information about RCT across the groups was internet, especially social media and the second best source of information was friends and relatives (P < 0.001) [Figure 2].
Figure 2: Source of first information about root canal treatment in the two groups surveyed. Friends/relatives (1), dentist (2), internet (3), and none (4). Med: Medical student, HS: High school student

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Nearly 44% of Group 1 and 45% of Group 2 knew that their tooth could be saved by RCT [Figure 3]. Significantly, 10% and 17.5%, respectively, thought RCT may be needed sometimes even when tooth is asymptomatic (P < 0.01) [Figure 4].
Figure 3: Level of basic knowledge of root canal treatment in the surveyed groups. Save the tooth (1), remove the tooth (2), and don't know (3). Med: Medical student, HS: High school student

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Figure 4: Representation of when the participants think root canal treatment is done. Painful tooth (1), dead tooth (2), and don't know (3). Med: Medical student, HS: High school student

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About 51.3% and 50.3%, respectively, preferred RCT [Figure 5] and 56% and 62% believed that they may have to visit the dentist 2–5 times to complete RCT [Figure 6].
Figure 5: Treatment preferred when the tooth is painful. Have root canal treatment (1), remove the tooth (2), and don't know (3). Med: Medical student, HS: High school student

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Figure 6: Number of visits needed to complete root canal treatment. One visit (1), 2-3 visits (2), more than 5 visits (3), and don't know (4). Med: Medical student, HS: High school student

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Part 3 of the questionnaire had 6 questions exclusively for participants who have had at least one RCT in the past. 24.7% Group 1 and 42.2% from Group 2 had at least 1 root canal treated tooth (P < 0.01). 16.7% and 25.3% from respective groups did not report any inconvenience from the past RCT whereas 8.7% and 17% had complaints. Certainly, among those complainants, root canal procedure was painful to 53.3% and 47.4% from the respective groups. Other minor complaints included difficulty due to multiple appointments as well as long and tiresome nature of the procedure [Figure 7].
Figure 7: Type of inconveniences experienced by the participants during root canal treatment. Pain (1), multiple appointments (2), and long procedure (3). Med: Medical student, HS: High school student

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64.7% of both groups informed us that if needed they would opt for RCT in the future too. Among the 35.3% of the two groups, the major reason for opting out of RCT is the hearsay about bad experiences from their friends and relatives as shown in [Figure 8]. Other reasons are pain, shortage of time, and unaffordability in the descending order. 57.3% of Group 1 and 52% of Group 2 informed us that they would recommend RCT to their friends and relatives.
Figure 8: Real reasons why people do not opt for root canal treatment in the future. Previous pain (1), shortage of time (2), unaffordable (3), and bad experience of friends/relatives (4). Med: Medical student, HS: High school student

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  Discussion Top

The general objective of the present study was to conduct the survey and use the information to streamline the dental health-care system of College of Dentistry under the Al Jouf University. We believe that this should be a sufficient motivation to perform this study even at the risk of repetition.

Access to quality health services has been declared as a basic human right by the WHO.[8] Providing it, overcoming all sociocultural and behavioral barriers is considered to be the duty of all the governments.[9] Paucity of funds can be a dampener for most of the third world countries, forcing the governments to seek active collaboration with the private sector.[10] According to the WHO report in 2000, Saudi Arabia is ranked 26th among 190 other world nations in terms of the quality of public health-care infrastructure and facilities.[11] Hence, at least here in the Kingdom of Saudi Arabia (KSA), shortage of facilities and expertise could not be considered as a limitation. College of Dentistry, Al Jouf University along with specialty centers of the Ministry of Health serve the people of Sakaka Province.

RCT saves teeth and unquestionably improves the quality of life.[12] This impact has been verified to be universal and found to be regardless of the cultural backgrounds.[13] Patient's treatment decisions are strongly influenced by his social, psychological, and behavioral factors such as education, financial status, attitudes, believes, and preferences.[14] Even a well-informed person has to deal with extraneous factors such as treatment-related anxiety, fear, pain, cost, and expectations.[15] Patients with high anxiety often prolong or avoid dental treatments. Anxiety is defined as the fear of the unknown.[16] The implication of this definition is that most often it is an indicator of ignorance. This would mean that it is easy to eradicate it by educating the masses. Studies in the past had highlighted the need to provide more information about the advantages of retaining natural teeth.[5]

Our study being the first to be undertaken in the Sakaka Province was an earnest attempt at gathering information on the prevalent situation in the city. Medical school and the local high school were selected for the survey due to their accessibility. Gender predilection could not be studied since both these institutions had only male students. Several studies in the past like Armfield and Heaton, 2013 stated that people with higher education levels are highly motivated in life and pursue healthy lifestyles and are more likely to take positive health decisions. These people are more adept at handling the anxiety factor too.[17] Hence, it was a surprise to see that in our study, irrespective of the education status, both medical school (84%) and high school (82.8%) students approached dentist only on the appearance of pain. Across the groups, we also found that regular maintenance visit was barely practiced. Participants from both groups knew about RCT, but we were a bit surprised again to find out that comparatively more high school students (59.5% against 48.7%) are aware of the treatment procedure. It was subsequently revealed that most of the participants got their first information about RCT from the media (29.3% and 50.6%), especially the internet. This was also true in the case of two studies, Sisodia et al.[5] and Doumani et al.[6] mentioned earlier. In fact, most of the participants we interviewed are quite active in social media platforms such as Snapchat, Twitter, and Instagram from where they had accessed information on various endodontic procedures. The second most common source of information is friends and relatives, followed by dentists. This is also in agreement with the findings of the past study.[12] Power of the social media could be exploited well to enlighten the ignorant ones (50.7% and 40.5%) about the opportunities provided by the modern-day endodontics.

As stated earlier, most of the participants (55.3% and 57.8%) approached the dentist for RCT on appearance of pain. Appearance of pain is an indication that tooth is already in an advanced state of damage escalating the cost of treatment too. Public should be informed that it is desirable to intercept the problem early enough not only to prevent pain from curtailing their normal life but also to keep the treatment charges low. Health policy-makers ideally like to see educated public seeking treatment on time. After appearance of pain treatment options available is root canal and preservation of tooth, extraction without replacement and extraction with subsequent replacement. Often patients opt for the extraction only option because of the lowest initial cost factor. However, tooth loss is often associated with significant issues, the most serious being its psychosocial impact. Physiologic impact may be relatively minor, but surgical complications, complicated healing, and its sequelae are imminent. RCT and implant-supported single crown have similar initial survival rate, so retention of the periodontally healthy tooth should be preferred to the more expensive implant-retained prosthesis.[18] Extraction followed by fixed partial dentures has comparatively poor long-term survival rates.[19] We were alarmed to find out that 40.7% of the participants did not have any clue about RCT. It was 29% in a similar study conducted in the KSA mentioned earlier.[6] Vigorous well-planned awareness campaigns highlighting the advantages of retaining natural teeth could be organized by dental associations. Social media should be drafted in to add impetus to these programs, especially among the youth.

The third part of the questionnaire exclusively meant for those with at least one past root canal experience was specifically planned to provide information on the attitude of the participants toward RCT after the past experience. Intraoperative pain is usually a huge concern, as along with pain-related anxiety, it is the most common reason why people avoid RCT.[19] In our survey, intraoperative pain was the second most significant reason, probably because of the relatively lesser number of RCTs among the participants. Findings of Sisodia et al., 2008[5] and Janczarek et al., 2014[3] substantiate the fact that intraoperative pain and pain-related anxiety are indeed the most powerful deterrents to RCT. There have been several studies on pain perceptions and its impact on RCT. Once again, Sisodia et al., 2008 observed that 24% of the surveyed decided not to get root canal treated because they thought it would be very painful; only 10% of the people who got treated felt pain.[5] Most patients admitted that actual pain during the procedure has been found to be much less than what was expected in most cases. In cases with severe preoperative pain, relief after the initiation of procedure was so drastic and dramatic that most admitted that they would prefer RCT to extraction in the future too.[20] In fact, most of the participants informed us that they would recommend RCT to their near and dear ones; a view shared by many other studies too.[5],[20]

In either group, 35.3% of participants with the past root canal experience confessed that they would prefer extraction to RCT. Majority of them (52% and 51.4%) got sensitized because of the horrific experience of their friends or relatives. Subjective fear, generates anxiety, is the most common reason for avoidance or delayed RCT.[21],[22] Dental professionals should be trained well to identify these anxious patients so that their worst fears about RCT could be allayed. Other minor reasons to avoid RCT in our survey were shortage of time and unaffordability. Single-visit endodontics performed by specialist would most certainly address the former.[23] Only 9.3% and 8.3% from the respective groups surveyed by us confessed that the cost factor was the reason for avoiding RCT. This result is in agreement with Doumani et al., 2017[6] where 72% of respondents confirmed that cost does not affect their treatment decision; in fact, 67% mentioned that they would undergo the procedure at any cost. Several other studies[3],[5],[24] revealed that high treatment cost has significant negative impact on treatment decision. People who cannot afford the cost should not be denied treatment under any circumstances and public should be informed about the services provided by several public institutions under the Ministry of Health.

The present study would be further elaborated by the inclusion of parameters such as gender and financial status. Even with the small sample size, we had at our disposal, it is reassuring to find out the young generation is aware of advances in the field of dentistry. They have deep concerns regarding their oral health and are keen to retain their natural teeth. Extraction is no longer accepted as the norm and most of them are determined to get root canal treated at any cost. Professional organizations and government bodies just need to come up with regular campaigns exploiting internet platforms such as Twitter and Snapchat to disperse knowledge and dispel misconceptions about dental problems and treatment procedures.

  Conclusion Top

  • Students of the age group 17–19 years are reasonably informed about RCT. However, they need to be made aware of the benefits of regular, periodic dental checkup in saving their teeth
  • Comparatively, more students of the age group 13–16 years are aware of the treatment modalities in endodontics. In a way, this contradicts the view that practice of RCT is directly proportional to the educational status. We conclude that this may be due to the popularity of internet platforms among the younger group
  • At the regional level, health-care planners and policy-makers should come up smarter plans targeting the youngsters. These campaigns could be more efficient if internet platforms are exploited to further their reach.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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