|Year : 2021 | Volume
| Issue : 1 | Page : 80-87
Knowledge-, attitude-, and practice-based survey on instrument separation and its management among endodontists and postgraduates in India - A cross-sectional web-based questionnaire
DP Shilpa-Jain1, Sneha Susan Santosh1, Durvasulu Archana2, Surendran Smita1, Parashar Saumya-Rajesh1, Natanasabapathy Velmurugan1
1 Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College and Hospital, Affiliated to Meenakshi Academy of Higher Education and Research, University (MAHER University), Chennai, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontics, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||07-Dec-2019|
|Date of Decision||22-Jan-2020|
|Date of Acceptance||15-Feb-2020|
|Date of Web Publication||09-Jan-2021|
Dr. Natanasabapathy Velmurugan
Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 600 095, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: The aim of this survey was to investigate the current knowledge and attitude toward intracanal instrument separation and the most common modality of treatment employed among endodontists and postgraduates in India.
Materials and Methods: A validated web-based questionnaire that comprised close-ended and partially close-ended questions in four categories was circulated by e-mail along with the informed consent to 1100 endodontists and postgraduates. The participants were asked about the frequency of instrument separation, possible etiological factors, management, and techniques used for instrument retrieval. Reliability was checked by asking ten random participants to fill the forms twice within a time frame of 15 days.
Statistical Analysis: The validity and reliability scores for the survey were calculated using content validity ratio and kappa test, respectively. All the analyses were performed using SPSS 16.0 software.
Results: A total of 499 responses were received, yielding a response rate of 45.3%. The content validity ratio was 0.9 and kappa scores for reliability were 0.98. The survey respondents comprised 47.6% of endodontists and 52.4% of postgraduates. Majority of the respondents (59.5%) opted to bypass, clean, and shape the canal and incorporate the separated instrument in the obturation. Ultrasonics (60.9%) was the most preferred technique for instrument retrieval of which 28.5% of the respondents used direct ultrasonic vibrations, 23.1% used indirect vibrations, and 48.4% used both direct/indirect vibrations.
Conclusions: The respondents of the survey were aware of the possible etiological factors and management techniques used for retrieval of the separated instrument. Majority of them chose to bypass the separated instrument. Ultrasonics under a dental operating microscope was the most commonly employed technique for retrieval.
Keywords: Indian endodontists, instrument separation, knowledge, attitude, and practice survey, retrieval techniques, root canal treatment
|How to cite this article:|
Shilpa-Jain D P, Santosh SS, Archana D, Smita S, Saumya-Rajesh P, Velmurugan N. Knowledge-, attitude-, and practice-based survey on instrument separation and its management among endodontists and postgraduates in India - A cross-sectional web-based questionnaire. Saudi Endod J 2021;11:80-7
|How to cite this URL:|
Shilpa-Jain D P, Santosh SS, Archana D, Smita S, Saumya-Rajesh P, Velmurugan N. Knowledge-, attitude-, and practice-based survey on instrument separation and its management among endodontists and postgraduates in India - A cross-sectional web-based questionnaire. Saudi Endod J [serial online] 2021 [cited 2021 Apr 15];11:80-7. Available from: https://www.saudiendodj.com/text.asp?2021/11/1/80/306606
| Introduction|| |
Currently, there are numerous instruments and equipment available for shaping and cleaning the root canal system. Nickel–titanium (NiTi) rotary instruments have gained widespread popularity in endodontics owing to its superelasticity, thus making it more favorable for effective instrumentation. Despite improvements in the instrument design, alloy composition, and manufacturing process, file separation during instrumentation remains a major concern for clinicians as it prevents the thorough debridement and sealing of the canal, apical to the level of separation.,, The incidence of separation for NiTi and stainless steel (SS) files ranges from 1.3% to 10%, and 0.25% to 6%,, respectively.
One of the most common methods of retrieval is the creation of a circumferential staging platform around the most coronal aspect of the fragment using the modified Gates-Glidden bur, followed by the use of ultrasonic tips at a low-power setting.,, However, many devices, techniques, and methods are available for retrieving separated instruments such as the Masserann kit, Meitrac Endo Safety System, Feldman technique, instrument removal system (IRS), Endo Rescue system, Cancellier Extractor kit, and the Endo Extractor System.
A previous survey conducted by Karunakar et al. on the management of instrument separation among Indian endodontists and postgraduates was done in 2015. At present, there is a lot of emphasis on the use of magnification, which has made this procedure more predictable. In addition, newer instrument retrieval techniques such as Terauchi File Retrieval Kit and the GentleWave Multisonic Ultracleaning System are also available., The percentage of success for managing a separated instrument (bypass and retrieval) in clinical studies ranges from 53% to 95%.,,, Hence, it will be interesting to know which among these techniques is currently being used by Indian endodontists and postgraduates.
Therefore, the aim of this survey was to investigate the current knowledge and attitude toward intracanal instrument separation and the most common modality of treatment employed among endodontists and postgraduates in India.
| Materials and Methods|| |
A cross-sectional web-based survey was carried out among endodontists and postgraduate students in India on the knowledge, attitude, and practice (KAP) toward the management of separated intracanal endodontic instruments. An invitation to participate in the KAP survey was sent via electronic mail to 1100 members of the Indian Association of Conservative Dentistry and Endodontics after obtaining approval from the Institutional Review Board (IRB. NO MADC/IRB-XX/2018/351). The questionnaire [Table 1] was accompanied by a covering letter and informed consent stating the aim and objective of the study. First-year postgraduate students were excluded from the survey.
The attitude- and knowledge-based questions were on a five-point Likert scale, while the other questions were close ended or multiple choice based. The initial set of 25 questions was validated by five experts in the field of endodontics. Content validity ratio was determined based on the expert opinion; 5 questions (3 in practice and 2 in attitude) were eliminated from the questionnaire and ten questions were reframed. The final questionnaire consisted of 20 questions which were then divided into four sections, namely (a) demographics: 1 question, (b) knowledge: 3 questions, (c) attitude: 3 questions, and (d) pattern of practice: 13 questions. Based on the results of the pilot survey, a sample size of 389 was obtained. Reliability was checked by asking ten random participants to fill the forms again within a time frame of 15 days.
The questionnaire was developed using Google Forms (Google Inc. Mountain View, CA, USA). The data were stored into an Excel format in the backend until further analysis. The validity and reliability scores for the survey were calculated using content validity ratio and kappa test, respectively. All the analyses were performed using SPSS 16.0 software (IBM Corp., Chicago, IL, USA).
| Results|| |
A total of 499 responses were received out of 1100 forms yielding a response rate of 45.3%. The content validity ratio was 0.9, and kappa scores for reliability were 0.98.
The survey respondents comprised 47.6% of the endodontists and 52.4% of the endodontic postgraduates.
About 71.9% of the respondents strongly agreed/agreed that previous pulpal status had an influence on the prognosis of the treatment outcome, while 19.2% were unaware and 8.9% strongly disagreed/disagreed with it. The influence of location and size of the fractured instrument on retrieval are illustrated in [Figure 1].
|Figure 1: Reply of the participants (knowledge) regarding the influence of location and size of the fractured instrument on retrieval|
Click here to view
Majority (92%) of the respondents strongly agreed/agreed that a dental operating microscope (DOM) is mandatory for instrument retrieval; nonetheless, 5.1% of the respondents were not sure and 2.9% of the respondents disagreed. The results of the other attitude-based questions are illustrated in [Figure 2].
|Figure 2: Reply of the participants (attitude) regarding informing the patients and the visibility of the fractured instrument|
Click here to view
Instrument separation was experienced by 89.5% of the respondents, while 10.5% did not experience it. Among these, 66.4% of the respondents experienced separation very rarely, while 33.6% experienced it frequently. The commonly fractured file was reported to be NiTi rotary (60.9%) followed by SS (12.7%) and NiTi Hand file (3.2%). The common location of instrument separation, probable reasons for its separation, relative root canal, primary management, and the possible consequences experienced by the respondents are illustrated in [Figure 3]. Most (60.5%) of the respondents experienced instrument separation during shaping and cleaning; however, 10.8% of the respondents encountered it during the initial stages of root canal negotiation. The remaining 28.7% of the respondents felt that it can occur both during negotiation and while shaping and cleaning.
|Figure 3: Reply of the participants (practice) regarding the fractured instrument and its management|
Click here to view
Ultrasonics with a staging platform (60.9%) was the most commonly employed technique. The other chosen methods were the Masserann kit (10.1%), IRS (5.1%), Terauchi File Retrieval kit (2.1%), and wire-loop technique (0.6%), while 20.6% of the respondents used a combination of techniques and 0.6% used others. When using ultrasonics, 28.5% of the respondents opted for direct vibration, while 23.1% used indirect vibration and 48.4% used both direct/indirect vibrations. Instrument retrieval from the apical third was considered to be more challenging by 92.8% of the respondents compared to the middle (5.7%) and the coronal third (1.5%) of the root canal.
| Discussion|| |
A survey enables one to acquire opinions from a large number of participants. This cross-sectional survey was conducted to evaluate the KAP among Indian endodontists and postgraduates toward instrument separation and its management. The response rate in the present survey was 45.3%, of which 47.6% were endodontists and 52.4% were postgraduate students.
Majority of the respondents (89.5%) experienced instrument separation during root canal treatment which was similar to a survey done by Madarati et al. in the UK population (88.8%). The commonly separated file was NiTi Rotary (60.9%), which was in accordance with earlier surveys conducted by Madarati et al. (76.7%) and Karunakar et al. (64.4%)., This, however, was contrasting to a survey conducted in Riyadh by Pedir et al. who found SS (65%) to be the most commonly fractured file during root canal procedure. These conflicting results may be attributed to the difference in the sample population comprising general dentists and undergraduate students in the Pedir et al.'s survey compared to qualified endodontists and postgraduate students included in the present survey.
The respondents (21.9%) of the present survey found multiple usage of files to be the most common reason for instrument fracture. Apart from fatigue-related issues, using a NiTi file multiple times subjects it to numerous irrigation and sterilization cycles, which in turn causes surface imperfections and corrosion, thereby leading to more chances of file separation. Adoption of a single-use policy seems appropriate to avoid such clinical mishaps and cross-infection in patients., Other reasons for instrument separation were improper file motion with the application of excessive pressure (12.2%) and complex root canal anatomy (7.0%). Similar results were found in surveys conducted by Parashos and Messer in the Australian population (85%) and Pedir et al. in the Riyadh population (45%).,
The junction of the middle and apical third (48.1%) of the mesiobuccal canal (57.7%) of molars (96.2%) was reported to be the most common location for instrument separation. This is in accordance with the earlier studies., The presence of abrupt canal curvatures and apical ramifications in the narrow mesiobuccal canal of maxillary and mandibular molars could possibly be the reason for higher instrument separation in these canals., In addition, cyclic fatigue and torsional overload induce repeated cycles of tension and compression on the file resulting in fracture at the point of maximum flexure. Therefore, it is recommended that the file is used with a gradual, continuous movement in an axial direction to avoid concentration of fatigue on specific parts of the instrument, thereby reducing the chances for its fracture.,
The conclusion derived from a systematic review done by Panitvisai et al. states that the presence of a periapical lesion in a tooth with instrument separation compromises the healing. However, according to McGuigan et al., the prognosis of teeth with a retained instrument fragment depends on the preoperative condition of the periapical tissue and the stage of canal disinfection. In the presence of a periapical lesion, endodontic treatment is compromised and has demonstrated reduced healing. In the present survey, 71% of the respondents agreed to the same, which is in accordance to a survey done by Pedir et al.(77%). Moreover, the majority of the respondents in the current survey experienced instrument separation during cleaning and shaping (60.5%), which is comparable to a recent survey done by Avoaka-Boni et al.(55%). The extent of root canal disinfection correlates to the stage of instrumentation, i.e., when the instrument separates during the initial stages of root canal treatment, disinfection is compromised compared to when it separates during the later stages of root canal treatment subsequent to chemomechanical disinfection. Thus, establishing it is an important prognostic factor for the treatment outcome in retrieval cases.
The success of instrument retrieval is multifactorial which depends on numerous factors such as the type, size, and location of the fragment. In the present survey, bypassing the separated instrument was the most commonly employed treatment of choice by 59.5% of the respondents. This may be attributed to the fact that it is the first clinical step made to establish patency to the apical foramen which allows effective debridement and obturation till the apex without removing an excessive amount of radicular dentin. While making an attempt to bypass a separated instrument, chances of a ledge formation, perforation, transportation, and fracture of another file are also likely to occur, which can be prevented with good operator skills., However, contrasting to the earlier studies conducted by Al-Nazhan et al. and Karunakar et al., only 19% and 17.4% of the respondents, respectively, opted to bypass the separated instrument, while the vast majority (76.8%) chose to leave the separated fragment in the canal and review if the instrument separation occurred at the apical third. This striking difference in the results with Karunakar et al. survey could be attributed to the fact that the current survey questionnaire included only the general management of instrument separation without emphasis on the canal thirds.
An attempt to retrieve the fragment from the canal was chosen by 31.2% of the respondents in the present survey. Among the retrieval methods, ultrasonics with a staging platform was the most frequently employed technique by 60.9% of the respondents. This finding is similar to the results reported earlier by Madarati et al. in the UK population (84.6%), Pedir et al. (42%) in the Riyadh population, and Al-Nazhan et al. in the Saudi population (50%).,, The current survey reveals that there has been an increase in the adoption of ultrasonic retrieval technique when compared to an earlier survey done by Karunakar et al., wherein only 39.7% of the respondents used ultrasonics.
The ultrasonic technique requires direct/indirect contact of the vibrating tip with the metallic object to be retrieved. Initially, hand K-files or spreaders were mounted on the ultrasound handpiece and then activated at low-power settings to retrieve the fragment. Currently, a wide range of ultrasonic tips of different angulations, lengths, and sizes are available that are manufactured from a range of metal alloys such as SS or titanium based with an abrasive coating. However, there is a difference in the response of NiTi and SS instruments to the ultrasonic vibration. SS instruments bodily absorb the ultrasonic energy, showing early movement or dislodgment from the canal when compared to the brittle NiTi instruments. This may be attributed to the rotational movement of the NiTi file that renders deeper locking into the canal during separation. In such situations, direct ultrasonic energy can result in a secondary fracture of the fragment to be retrieved leading to more undesirable complications. Moreover, the feature of shape memory also adds to the challenging retrieval of smaller separated NiTi fragments as they tend to straighten and reengage with the root canal wall as they are released from the dentin.
In addition to ultrasonics, respondents chose other holding techniques such as the Masserann kit (10.1%) and IRS system (5.1%) that employ the concept of exposing 2 mm of the coronal portion of the fragment using a range of trephine drills or ultrasonic tips. This is followed by the use of hollow tubes/extractors to grasp and retrieve the separated instrument., Nonetheless, its use in the posterior teeth with thin and slender canals is limited, and the risk of perforation is also higher.
The conventional wire-loop technique was chosen by 0.6% of the respondents which aims at removing the segment by encircling and tightening it with a loop made up of a 25-gauge wire having an external diameter of 0.46 mm. However, a newer system, i.e., Terauchi File Retrieval Kit, was chosen by 2.1% of the respondents. This kit contains a tiny titanium wire loop at the end of the SS cannula with a sliding handle. In addition, it also contains a modified Gates Glidden #3 bur, microtrephine bur, and a micro explorer instrument loop. This technique involves the exposure of the fragment followed by the creation of space between the fragment and inner curve of the canal using ultrasonic vibration. If not retrieved, a loop device made of NiTi wire is introduced to mechanically engage the peripherally exposed fragment. Short retrieval times and removal of less dentin are the advantages of this kit as claimed in the laboratory and clinical studies.
A survey done by Madarati et al. in the UK population reflects contrasting results to the present survey, wherein 67.3% of the endodontists used multitechniques. In the present study, adoption of other techniques for retrieval (20.6%) was comparable to the survey done by Karunakar et al. in the Indian population (14%).
Modern endodontic practice involves the use of a DOM as it aids in direct and enhanced visualization under illumination. Almost 92.8% of the respondents reported that DOM should be used for instrument retrieval, which is in line with various earlier studies (87%–93%)., According to a prospective clinical study, the success rate improves if the coronal part of the fragment is visible under the DOM when compared to a fragment that cannot be visualized. About 75.4% of the respondents of the present survey agreed to the same.
The most frequent mishap encountered was ledge formation (34%), which was in agreement with the survey done by Pedir et al.(29%), although in contrast to Madarati et al. who reported excessive sound dentin removal as a common complication. The potential for the excess removal of dentin could be minimized with the use of ultrasonics and visual control with DOM.
Although a survey gives an insight into the opinions and attitudes of the respondents, it has some limitations such as its cross-sectional nature and chances of a response bias. In addition, instrument separation is an undesirable incident for any clinician and the management of such a clinical mishap is always specific to a situation that depends on time, as well as on the patient's compliance.
| Conclusions|| |
Within the limitations of this survey, it was observed that the participants of the survey were aware of the possible etiological factors and management techniques used for retrieval of the separated instrument. Bypassing the separated instrument was the most commonly employed technique followed by the use of ultrasonic in combination with DOM.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of nitinol root canal files. J Endod 1988;14:346-51.
Lambrianidis T, editor. Prevalence of fractured instruments. In: Management of Fractured Endodontic Instruments. Cham, Switzerland: Springer; 2018. p. 1-30.
Avoaka-Boni MC, Désiré Kaboré WA, Gnagne-Koffi YN, Djolé SX, Kouadio KT. Frequency of complications during endodontic treatment: A survey among dentists of the town of Abidjan. Saudi Endod J 2020;10:45-50. [Full text]
Alhekeir DF, Al-Sarhan RA, Mokhlis H, Al-Nazhan S. Endodontic mishaps among undergraduate dental students attending King Saud University and Riyadh Colleges of Dentistry and Pharmacy. Saudi Endod J 2013;3:25-30. [Full text]
Knowles KI, Hammond NB, Biggs SG, Ibarrola JL. Incidence of instrument separation using light speed rotary instruments. J Endod 2006;32:14-6.
Baumann MA, Roth A. Effect of experience on quality of canal preparation with rotary nickel-titanium files. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:714-8.
Iqbal MK, Kohli MR, Kim JS. A retrospective clinical study of incidence of root canal instrument separation in an endodontics graduate program: A pennendo database study. J Endod 2006;32:1048-52.
Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. J Endod 2005;31:845-50.
Madarati AA, Watts DC, Qualtrough AJ. Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intra-canal fracture of endodontic instruments. Part 2. Int Endod J 2008;41:1079-87.
Pedir SS, Mahran AH, Beshr K, Baroudi K. Evaluation of the factors and treatment options of separated endodontic files among dentists and undergraduate students in Riyadh Area. J Clin Diagn Res 2016;10:ZC18-23.
Al-Nazhan S, Al-Attas MH, Al-Maflehi N. Retrieval outcome of separated endodontic instruments by Saudi endodontic board residents: A Clinical retrospective study. Saudi Endod J 2018;8:77-81. [Full text]
Karunakar P, Jayadev M, Soumya Chinmayi S, Siddhartha P. A national wide survey of opinions and attitude of endodontists towards the intra canal separation of endodontic instruments. Endodontology 2015;27:101-6. [Full text]
Terauchi Y. Separated file removal. Dent Today 2012;31:108, 110-3.
Wohlgemuth P, Cuocolo D, Vandrangi P, Sigurdsson A. Effectiveness of the gentle wave system in removing separated instruments. J Endod 2015;41:1895-8.
Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J 2005;38:112-23.
Cujé J, Bargholz C, Hülsmann M. The outcome of retained instrument removal in a specialist practice. Int Endod J 2010;43:545-54.
Nevares G, Cunha RS, Zuolo ML, Bueno CE. Success rates for removing or bypassing fractured instruments: A prospective clinical study. J Endod 2012;38:442-4.
Ungerechts C, Bårdsen A, Fristad I. Instrument fracture in root canals – Where, why, when and what? A study from a student clinic. Int Endod J 2014;47:183-90.
Madarati AA, Watts DC, Qualtrough AJ. Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intracanal fracture of endodontic instruments: Part 1. Int Endod J 2008;41:693-701.
Valois CR, Silva LP, Azevedo RB. Multiple autoclave cycles affect the surface of rotary nickel-titanium files: An atomic force microscopy study. J Endod 2008;34:859-62.
Arens FC, Hoen MM, Steiman HR, Dietz GC Jr. Evaluation of single-use rotary nickel-titanium instruments. J Endod 2003;29:664-6.
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. [Full text]
Parashos P, Messer HH. Questionnaire survey on the use of rotary nickel-titanium endodontic instruments by Australian dentists. Int Endod J 2004;37:249-59.
Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics 2005;10:3-29.
Zelada G, Varela P, Martín B, Bahíllo JG, Magán F, Ahn S. The effect of rotational speed and the curvature of root canals on the breakage of rotary endodontic instruments. J Endod 2002;28:540-2.
Gambarra-Soares T, Lopes HP, Oliveira JC, Souza LC, Vieira VT, Elias CN. Dynamic or static cyclic fatigue tests: Which best determines the lifespan of endodontic files? Endod Prac Today 2013;7:101-4.
Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a retained instrument on treatment outcome: A systematic review and meta-analysis. J Endod 2010;36:775-80.
McGuigan MB, Louca C, Duncan HF. The impact of fractured endodontic instruments on treatment outcome. Br Dent J 2013;214:285-9.
McGuigan MB, Louca C, Duncan HF. Clinical decision-making after endodontic instrument fracture. Br Dent J 2013;214:395-400.
Madarati AA, Hunter MJ, Dummer PM. Management of intracanal separated instruments. J Endod 2013;39:569-81.
Park E. Ultrasonics in endodontics. Endod Topics 2013;29:125-59.
Cohen S, Gary D, Glassman G, Mounce R. Rips, strips and broken tips: Handling the endodontic mishap Part II: The separated instrument. Oral Health 2005;22:10-20.
Masserann J. “Entfernen metallischer fragmente aus wurzelkanälen” (Removal of metal fragments from the root canal). J Br Endod Soc 1971;5:55-9.
Chauhan R, Chandra A, Singh S. Retrieval of a separated instrument from the root canal followed by non-surgical healing of a large periapical lesion in maxillary incisors-a case report. Endodontology 2013;25:68-73.
Yoldas O, Oztunc H, Tinaz C, Alparslan N. Perforation risks associated with the use of masserann endodontic kit drills in mandibular molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:513-7.
Roig-Greene JL. The retrieval of foreign objects from root canals: A simple aid. J Endod 1983;9:394-7.
Terauchi Y, O'Leary L, Suda H. Removal of separated files from root canals with a new file-removal system: Case reports. J Endod 2006;32:789-97.
Terauchi Y, O'Leary L, Kikuchi I, Asanagi M, Yoshioka T, Kobayashi C, et al
. Evaluation of the efficiency of a new file removal system in comparison with two conventional systems. J Endod 2007;33:585-8.
[Figure 1], [Figure 2], [Figure 3]