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ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 59-65

A survey over the undergraduate students' approaches toward the management of endodontic emergencies at the Dakar Dental School: A descriptive cross-sectional study


Department of Conservative Dentistry and Endodontics, Faculty of Medicine, Cheikh Anta Diop University of Dakar, Dakar, Sénégal

Date of Submission23-Sep-2019
Date of Decision29-Nov-2019
Date of Acceptance15-Jan-2020
Date of Web Publication09-Jan-2021

Correspondence Address:
Prof. Khaly Bane
Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University of Dakar, BP: 5005, Dakar
Sénégal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_145_19

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  Abstract 


Introduction: Endodontic emergencies are characterized by violent or disabling pain. The management of these emergencies requires a precise diagnosis and an emergency act with or without a prescription. This study primarily aimed to determine undergraduate students' knowledge on the management of endodontic emergencies at the dental school.
Materials and Methods: In this cross-sectional descriptive study, students of the dental school have received questionnaires with two main parts: a first part dealing with students' identification and a second part dealing with students' knowledge and attitudes on endodontic emergency management. Participants were asked to choose the appropriate option (s) for the appropriate management of each type of endodontic emergency. Data were statistically analyzed.
Results: Of the 176 students included in this study, 171 questionnaires (97.2%) were completed and returned to the authors. For each emergency, most of the respondents recommended options that are consistent with the standard protocol. The statistical analysis showed a significant correlation between correct responses according to the standard protocol and academic levels of students who attended a conference or training on endodontic emergencies and students who dealt with endodontic emergency during their training (P < 0.05).
Conclusion: The study showed that the students' level of knowledge is high. However, they recommended inappropriate antibiotic prescriptions. This shows the need to improve student-training programs on endodontic emergencies.

Keywords: Attitude, Dakar, endodontic emergency, knowledge, treatment modalities, undergraduate students


How to cite this article:
Bane K, Sarr M, Diène MN, Diop EC, Touré B. A survey over the undergraduate students' approaches toward the management of endodontic emergencies at the Dakar Dental School: A descriptive cross-sectional study. Saudi Endod J 2021;11:59-65

How to cite this URL:
Bane K, Sarr M, Diène MN, Diop EC, Touré B. A survey over the undergraduate students' approaches toward the management of endodontic emergencies at the Dakar Dental School: A descriptive cross-sectional study. Saudi Endod J [serial online] 2021 [cited 2021 Jan 22];11:59-65. Available from: https://www.saudiendodj.com/text.asp?2021/11/1/59/306600




  Introduction Top


Endodontic emergencies is an important part of dental emergencies, accounting for approximately 60% of the reasons for consultation.[1] Among these, acute irreversible pulpitis is one-third of cases, whereas acute periapical pathologies of endodontic origin are most of the other two-thirds. These emergencies may occur before, during, or immediately after a root canal treatment and a completed root canal filling.[2],[3],[4] The etiological treatment of these pathologies is conservative but necessarily interventional. In both cases, it is necessary to shape the root canals and clean the root canal system before a hermetical sealing. This procedure, called endodontic treatment, can be done in one step in the case of acute irreversible pulpitis or by drainage in the case of acute periapical pathologies. This etiological treatment is long and resource consuming; it is, therefore, common on an emergency basis, except in very special cases.[5],[6],[7]

Thus, to relieve patients and avoid any infectious complications, emergency treatment should be carried out in most of the cases before etiological treatment.[7] However, the choice of this emergency treatment is not simple. Indeed, although there is much controversy about the way endodontic emergencies are handled, little research on the subject is available in the endodontic literature.[8] Therefore, for dentists, it is essential to have sufficient knowledge and information on appropriate treatment protocols to properly manage these types of dental emergencies.[2]

Currently, educators are addressing specific needs of target populations to develop appropriate educational programs. Indeed, the evaluation of the learning protocol and its additional requirements is fundamental to the relevance of educational activities to a target audience.[9] This will help educators in curriculum planning to achieve their learning objectives.[10],[11] Data on students' knowledge and attitudes toward endodontic emergencies are rare. In Senegal, there is no study available on the subject.

This study aimed primarily to determine undergraduate students' knowledge of endodontic emergency management at the dental school.


  Materials and Methods Top


This was a descriptive cross-sectional survey during the 2018–2019 academic year. All 4th-, 5th-, and 6th-year students of the dental school during this period were included in the study (n = 176). The study was approved by the Ethical Committee of the Dakar Dental School (N° 0027/IOS).

An updated questionnaire similar to the one in the Dorn study[10] was used. The endodontic department staff approved its translated version. The question reliability was also approved. The test–retest method was used to better assess the reliability of the questionnaires which were distributed to 18 student volunteers. After 2 weeks, the same students were again given the same questionnaires. The kappa index was calculated at 0.81.

The questionnaires were to be completed by participating students and consisted of two main parts: a first part dealing with student identification (gender, academic level, conference or meeting related to endodontic emergency attendance, self-confidence in treating endodontic emergencies, and exposure to any endodontic emergency) and a second part dealing with students' knowledge and attitudes about endodontic emergency management. This last part contained various conditions of pulp/periapical emergencies and different modalities of treatment related to:

  • Symptomatic irreversible pulpitis and normal apical tissue
  • Symptomatic irreversible pulpitis and symptomatic apical periodontitis
  • Necrotic pulp with symptomatic apical periodontitis and no swelling
  • Necrotic pulp with fluctuant swelling and drainage obtained through canal
  • Necrotic pulp with fluctuant swelling and no drainage obtained through canal
  • Necrotic pulp with diffuse swelling and drainage obtained through canal
  • Necrotic pulp with diffuse swelling and no drainage obtained through canal
  • Severe interappointment pain
  • Severe interappointment pain and swelling
  • Severe pain after completion of root canal treatment
  • Severe pain and swelling after completion of root canal treatment
  • Pain in the failure of root canal treatment.


The modalities of treatment (13 in all) were pulpotomy, partial pulpectomy, complete instrumentation, retreatment, apical surgery, instrument beyond the apex, occlusion reduction, to leave tooth open, trephination, incision and drainage, and use of antibiotic, analgesic, and intracanal drugs. Participants were to choose the appropriate option (s) for the appropriate management of each type of endodontic emergency. It is, therefore, possible to have several answers for each type. The purpose and benefits of such study were explained participants. Some aspects of students' identity were not requested to ensure anonymity.

Qualitative variables were determined by their numbers, percentage, and age by means and standard deviation. The Chi-square analysis was used to determine the relationship between qualitative variables. Spearman's correlation analysis was used to assess the correlation between participants' correct responses and initial variables. For all tests, the significance level was set at P = 0.05. Descriptive and correlation analyses were generated using IBM SPSS Statistics 20 (Armonk, NY, United States).


  Results Top


Of the 176 students included in this study, 171 questionnaires (97.2%) were completed and returned to the authors: 100% (n = 63/63) in the 4th year, 100% (n = 64/64) in the 5th year, and 89.8% (n = 44/49) in the 6th year [Table 1]. The average age of students was 24.3 years ± 1.79, 60.2% (n = 103) were male, 37.4% (n = 64) attended a conference or training on endodontic emergencies, 93% (n = 159) reported having the confidence to treat endodontic emergencies, and 69.9% (n = 119) were exposed to an endodontic emergency.
Table 1: Initial variables characterizing the sample

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The descriptive statistics of responses are shown in [Table 2]a,[Table 2]b,[Table 2]c. The statistical analysis showed a significant correlation between correct responses according to the standard protocol and academic levels, students who attended a conference or training on endodontic emergencies, and students who were exposed to an endodontic emergency during their training. However, there was not any correlation between correct responses, gender, and self-confidence in the treatment of endodontic emergencies.


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  Discussion Top


This study was carried out at the dental school in Sénégal. Fourth-, 5th-, and 6th-year students were chosen because the theoretical and clinical training of students on the management of endodontic emergencies begins in the 4th year. The study aimed to determine the knowledge of these students regarding the management of various endodontic emergencies based on a standard protocol. Studies on the management of endodontic emergencies are rare, and there is a real controversy in treatment modalities found in the endodontic literature. The treatment modalities vary from one textbook to another. Treatment plans in this study were based on two textbooks considered to be the references in the training of undergraduate students.[2],[6] Previous studies on the subject have also used these manuals to establish a standard protocol.[8],[11]

Concerning the emergency management of symptomatic irreversible pulpitis without apical periodontitis, 57.3% of the students would perform complete instrumentation, whereas 40.3% chose partial pulpectomy and 81.9% pulpotomy. Many endodontic textbooks have described complete instrumentation as the ideal treatment. This emergency objective was to significantly reduce the intrapulpal pressure created by inflammation by eliminating as much inflammatory pulp tissue as possible.[2],[6] Natkin's work has shown that complete instrumentation allows a significant decrease of symptomatic irreversible pulpitis pain related.[12] However, when time is limited, partial pulpectomy of anterior teeth and pulpotomy of posterior teeth are recommended. In the latter case, if hemostasis cannot be obtained, it is recommended to perform the pulpectomy of the largest canal.[2],[6],[13]

In case of symptomatic irreversible pulpitis with symptomatic apical periodontitis, 66.1% of the respondents have chosen complete instrumentation and 57.3% occlusal reduction. As in the previous emergency situation, complete instrumentation is the ideal treatment proposed by many authors, in addition, it must be completed with occlusal reduction due to inflammation of apical tissues.[2],[14],[15],[16] In the study by Dorn et al.,[10] 80% of the respondents suggested occlusion reduction, whereas the Alamoudi study showed that 68.4% suggested this option.[8]

In necrotic teeth without swelling, the most common and standard emergency treatment includes complete instrumentation, occlusal reduction, prescription of analgesics, and application of intracanal medicaments.[2],[6],[10] Complete instrumentation will eliminate necrotic pulp tissue and reduce the intracanal bacteria.[17] However, the evaluation of the root canal shaping associated with chemical irrigation showed that the number of bacteria is significantly reduced in canals. Nevertheless, 50% of the canals treated in this way still contain bacteria at the end of the session. Even if their number is low, they can rapidly proliferate between two sessions in the absence of an antiseptic, which shows the importance of using an intracanal one. Due to the acute inflammation of the apical periodontium, occlusal reduction of the tooth is recommended for pain relieving during interdental contact, especially during mastication.[14] In addition, the prescription of an analgesic is also indicated for pain relief.[14] In the present study, treatment preference of students was in accordance with this standard treatment: 76.7% complete instrumentation, 79.5% application of intracanal drug, 79.5% occlusal reduction, and 81.9% prescription of analgesics. Our results are in accordance with those obtained by Alamoudi[8] where 86.5% performed a complete instrumentation, 79.5% placed an intracanal drug, 43.7% performed an occlusal reduction, and 57.2% prescribed an analgesic drug. The study by Bidar et al.[11] showed differences in responses between endodontists and general dentists.

The standard protocol in case of necrotic pulp with fluctuant swelling and drainage obtained through canal includes complete instrumentation, incision and drainage, and analgesic and intracanal drugs. The results of our study showed that 72.5% of the students chose complete instrumentation, 59.1% incision and drainage, and 73.1% analgesic and 53.2% intracanal drugs. Similar findings were reported by Bidar et al.[11]

The other therapeutic option to treat this emergency is incision and drainage. Indeed, some authors consider that, sometimes, more than one abscess is possible. One is connected to the apex, and the other one is separately in the vestibule. Since they are not connected with each other, drainage through the tooth is not enough and incision is also necessary.[2] For this reason, Matthews et al.[18] have suggested that incision and drainage should be considered as a standard option in this emergency situation, as it would reduce pain and swelling.

In case of necrotic pulp with fluctuant swelling and no drainage obtained through canal, the standard protocol includes complete instrumentation, instrument beyond the apex, incision and drainage, and analgesic and intracanal drugs. The results of the present study were comparable to Bidar et al.[11] and Alamoudi.[8] Instrument beyond the apex was proposed by Bhaskar[19] who considers that 1 mm overinstrumentation beyond the apical foramen may help in draining inflammatory exudate and eliciting an inflammatory reaction that enhance healing of periradicular tissue. Care should be considered although this approach will not cause any damage to the surrounding vital structure as long as minimal overinstrumentation was ensured.[20]

In necrotic pulp with diffuse swelling and drainage obtained through canal, 98.2% of the students chose complete instrumentation; 81.9% incision and drainage; and 95.3% antibiotic, 99.4% antalgic, and 71.9% intracanal drugs. These treatment options are in accordance with the standard protocol.[2],[6] Incision and drainage, as well as antibiotic prescription, are of crucial importance in this emergency. Indeed, there may be more than one abscess, and in such case, drainage through the canal may not overcome the bacterial load in the diffuse swelling.[2] For some authors, antibiotic prescription helps prevent a possible complication of the infection that can lead to septicemia.[17] In the study by Alamoudi,[8] 27.4% of the dental interns have agreed to do incision and drainage and 94.4% antibiotic prescription.

The standard protocol in case of necrotic pulp with diffuse swelling and no drainage obtained through canal is similar to that of the previous emergency. Our results showed that 93.6% of the students chose complete instrumentation; 74.3% incision and drainage; and 95.9% antibiotic, 98.8% antalgic, and 72.5% intracanal drugs. Because drainage is not obtained through the canal, 1 mm overinstrumentation beyond the apical foramen may help in draining inflammatory exudate. Thus, 98.8% of the students in this study have chosen this option. In the study by Bidar et al.,[11] most of the respondents preferred instrumentation beyond the apex (40.8% of the dentists and 87.5% of the endodontists).

In case of severe interappointment pain, the standard protocol includes re-instrumentation, occlusal reduction, and analgesic prescription. Many students in this study recommended re-instrumentation (71.9%). Bidar et al.[11] reported that 75% of the endodontists and 37.5% of the dentists also recommended this option. For occlusal reduction and analgesic prescription, 74.3% and 98.8% of the student respondents recommended these options, respectively. These last two therapeutic options complete the re-instrumentation for a significant pain reduction.[21],[22],[23]

If severe interappointment pain is accompanied by swelling, drainage is required; standard protocol includes re-instrumentation, incision and drainage, instrument beyond the apex, analgesic prescription, and intracanal drug. About 96.5% of the students have recommended re-instrumentation. For swelling management, 95.3% recommended instrument beyond the apex and 70.2% incision and drainage.[24] In addition, 98.8% have chosen analgesic prescription and 90.1% placement of intracanal drug. These options are perfectly in line with the standard protocol.

The clinical characteristics of severe pain after completion of root canal treatment are common to descriptions of acute apical periodontitis. It is a continuous, slender, well-localized pain, aggravated by occlusal pressure or periapical palpation. In the case of treatment of teeth with vital or necrotic asymptomatic pulp, pain develops within hours or days of treatment, whereas in the case of a tooth with preoperative periodontal symptomatology, it will be persistence with worsening or improvement in the quality of preexisting pain (and therefore the absence of immediate deletion).[24] The standard protocol for managing this postoperative pain includes occlusal reduction and analgesic prescription. The results of this study are in line with this protocol since 63.7% of the respondents recommended occlusal reduction and all respondents (100%) analgesic prescription. This is similar to Bidar et al.[11] who showed that 100% of the respondents recommended analgesic prescription and 53% of the respondents recommended occlusal reduction. If postoperative pain is accompanied by swelling, in addition to the previous protocol, incision and drainage should be performed.[2],[6] Most of the students (97.7%) recommended incision and drainage in this study.

Endodontic failure is most often manifested by the occurrence of periradicular inflammatory lesion of endodontic origin, which is related to the presence of intracanal bacteria.[25] The latter and their toxins originated the periapical inflammatory reaction. Either there were bacteria before the initial treatment and some microorganisms could not be eliminated or they resisted the different antiseptic strategies. These are related to persistent or recurrent intraradicular infections.[26],[27],[28] Either bacteria were introduced during the initial treatment following an asepsis error, or in intersessions, or once the endodontic treatment was completed (coronary sealing problem). These are secondary intraradicular infections.[5],[6] In case of pain in failure of root canal treatment, the standard protocol includes retreatment, apical surgery, and analgesic prescription. The results of the current study showed that 98.8% of the students recommended endodontic retreatment, 51% apical surgery, and all (100%) analgesic prescription. Our study is in consistent with Alamoudi study[8] where 89.8% of the interns recommended retreatment, 34% apical surgery, and 83.7% analgesic prescription. In contrast, in the study by Bidar et al.,[11] 100% of the endodontists recommended apical surgery. These differences are certainly related to the fact that undergraduate students and interns are not well trained in apical surgery indications.

An important result that should be highlighted in this study is the recommendation of antibiotic prescription by students in all emergencies, especially in periapical pathologies. Overprescribing of antibiotics is also mentioned in similar studies. In Spain, the study of Segura-Egea et al. showed that 71% of the surveyed practitioners prescribed antibiotics for acute apical abscesses with localized swelling or without swelling.[29] The retrospective study by Mainjot et al. analyzing antibiotic prescriptions made by Belgian dentists over 2 weeks showed that 63.3% of the patients with periapical abscesses were treated with antibiotics and in more than 90% of these cases in the absence of general signs.[30] These excessive uses of antibiotics are in contradiction with many studies in which authors have demonstrated the ineffectiveness of antibiotics as a complement to a local act in the absence of systemic signs.[31],[32],[33],[34]

Analgesic prescription was also recommended in all emergencies. As Alamoudi[8] noted in her study, students can prescribe anything from nonnarcotic medications for mild-to-moderate pain to narcotic medications for severe pain.

The present study showed a significant correlation between correct responses according to the standard protocol and academic levels, students who attended a conference or training on endodontic emergencies, and students who were exposed to an endodontic emergency during their training. These results showed the importance of experience and continuing education for an effective management of endodontic emergencies by both students and practitioners.

This emphasizes the importance that endodontic emergencies should be an important part of students' initial training. One limitation of this study was the cross-sectional design. Furthermore, the anterior and posterior teeth were not separately evaluated.


  Conclusion Top


Most of the students participating in this study have a high level of knowledge of the management of endodontic emergencies. However, there was noted an inappropriate antibiotic prescription. This highlights the importance of improving students' management of endodontic emergency training programs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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