|Year : 2021 | Volume
| Issue : 1 | Page : 88-92
Radiographic evaluation of the quality of root canal filling performed by undergraduate students at Riyadh Elm University: A retrospective study
Budur Alosaimi1, Sarah AlHassan1, Hanan AlSiddiqi1, Sara Bin Bilal1, Bayan AlSiddiqi1, Musaed AlTammami2, Iman Mansy3
1 Dental Interns, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
2 Endodontic Consultant, Security Forces Hospital, Riyadh, Saudi Arabia
3 Lecturer, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
|Date of Submission||21-Dec-2019|
|Date of Decision||10-Feb-2020|
|Date of Acceptance||06-Apr-2020|
|Date of Web Publication||09-Jan-2021|
Dr. Budur Alosaimi
College of Dentistry Riyadh Elm University, Riyadh
Source of Support: None, Conflict of Interest: None
Introduction: The aim was to assess the quality of root canal filling and the frequency of procedural errors in
endodontic treatment performed by undergraduate students at Riyadh Elm University, Riyadh, Saudi Arabia.
Materials and Methods: Radiographic record of 306 postroot canals treated anterior and posterior teeth done by female undergraduate students between 2013 and 2019 were randomly selected. The root canal filling was evaluated using the following criteria: acceptable treatment comprises the following characteristics: uniform density, no voids, root canal filling 0–2 mm from the radiographic apex, and tapered: overfilling, underfilling, and inadequate density were considered unacceptable. Data were statistically analyzed.
Results: A total of 116 root canal fillings were done in the anterior teeth and 190 in the posterior teeth. In which 69.9% of root canal fillings were acceptable, and 66% of the treated teeth were in the maxilla. Patients with abscess and periapical pathology in radiograph had 2.11 times higher odds of unacceptable root canal fillings compared to patients with normal periapical radiographs, and the association was significant with 95% (confidence interval: 1.27–3.50) after adjusting for age, number of canals, tooth position, and location. About 13.7% of the unacceptable root canal fillings were underfilled.
Conclusion: The quality of root canal filling performed by female undergraduates was considered acceptable. Underfilling was the mostly identified treatment error. Hence, additional preparation is needed to improve the clinical aptitudes of the undergraduates for better endodontic treatment results.
Keywords: Dental students, procedural errors, quality, radiographic assessment, root canal filling
|How to cite this article:|
Alosaimi B, AlHassan S, AlSiddiqi H, Bilal SB, AlSiddiqi B, AlTammami M, Mansy I. Radiographic evaluation of the quality of root canal filling performed by undergraduate students at Riyadh Elm University: A retrospective study. Saudi Endod J 2021;11:88-92
|How to cite this URL:|
Alosaimi B, AlHassan S, AlSiddiqi H, Bilal SB, AlSiddiqi B, AlTammami M, Mansy I. Radiographic evaluation of the quality of root canal filling performed by undergraduate students at Riyadh Elm University: A retrospective study. Saudi Endod J [serial online] 2021 [cited 2021 Apr 15];11:88-92. Available from: https://www.saudiendodj.com/text.asp?2021/11/1/88/306607
| Introduction|| |
Root canal treatment (RCT) involves instrumentation and obturation of the root canal system to save teeth having pulp and periapical disease. Root canal procedure requires a high level of precision along with technical expertise for retaining and for keeping the tooth functional for the long term.
In endodontic, the outcome of RCT is an essential step of interest from a dentist's perspective. The most critical outcome of the RCT is the periapical status of a treated tooth, as it determines whether the ultimate goal of endodontic treatment has been achieved or not. The success of RCT relies on the quality of RCT. Therefore, it is important to evaluate the quality of RCT using different mechanisms. Failure of RCT is multifactorial and could be related to the inappropriate mechanical debridement, persistence of bacteria in the root canals and apex, poor obturation quality, over and under the extension of the root canal filling materials, and coronal leakage. Despite the success rate of 86%–98%, RCT should be evaluated clinically and radiographically intermittently to rule out any shortcomings and from preventing any irreversible damage.
Radiographic assessment of the quality of RCT has been reported in the literature by different studies, indicating that radiographic assessment could be used to indicate the chances of reinfection or any fault in the procedure of RCT.,,,,
Reviewing RCT done by undergraduate consistently guarantees that a sufficient standard of treatment is being conveyed, as there is no base degree of information or skill-based contribution for dental undergraduate that can be esteemed worthy. Furthermore, the current undergraduate will be future dentist; therefore, it is fundamental that the highest caliber of RCT is finished, so future patient consideration would not be undermined. In 2013, a survey study was conducted to evaluate endodontic errors among undergraduate dental students in two dental schools in Riyadh, Saudi Arabia; the reported percentage of endodontic errors was 68%. A recent questionnaire-based study reported that 56% of the 469 undergraduates from two dental schools in Riyadh reported at least one endodontic procedural error during their training. The high rates of root canal fillings error indicate insufficiencies in the practical knowledge, and this information is useful in improving the dental practices and outcomes of the treatment.
Therefore, it is important to audit the quality of RCT performed by undergraduate students promptly for improving the quality of educational programs and for improving the current practice.
The aim of the present study was to assess the quality of root canal filling and the frequency of procedural errors in endodontic treatment performed by undergraduate female students at Riyadh Elm University, Riyadh, Saudi Arabia.
| Materials and Methods|| |
This study was approved by the Research Center, College of Dentistry, Riyadh Elm University (RC/IRB/2018/1356). Data are retrieved anonymously and reported without breaching the privacy and confidentiality of the patients.
Postendodontically treated radiograph of 306 anterior and posterior teeth done by female undergraduate dental students (4th, 5th, and 6th year) in Al Namuthajya Campus in between 2013 and 2019 were retrieved from the patient's dental record. Cases were randomly selected from the patient charts, and the following data were analyzed: (1) file number, (2) age of patient, (3) date of receiving endodontic treatment, (4) pulpal and periapical diagnosis, (5) tooth number, and (6) root canal fillings procedure.
To evaluate the quality of RCT of each tooth at least three digital periapical radiographs were examined using SIDEX (SIDEXIS XG, Sirona, York, Pennsylvania, United States) and Dentalplus software (Admor DentalPlus Software Ltd Phoenix Parade Artex Avenue Rustington, UK), which includes preoperative periapical radiograph, working length determination radiograph, and postoperative radiograph. All the RCTs were manually done using K-files with 0.02 taper following standard step-back technique. Irrigation was done with 2% sodium hypochlorite and saline solutions. Obturation was carried out by lateral condensation using gutta-percha and an AH Plus sealer (Dentsply Maillefer, USA).
The radiographs were evaluated independently by two senior endodontists (with minimum experience of 5 years). Each endodontist independently evaluated the selected radiograph after internal calibration, and any discordant radiologic findings were reassessed and resolved by reappraisal and discussion of the case to reach a consensus and kappa statistics was calculated for inter- and intra-examiner validity, and it was 0.89 which is considerably good.
Evaluation of root canal filling
Criteria for evaluating root canal filling quality reported by the European Society of Endodontology were followed. The criteria were as follows: acceptable RCT comprises the following characteristics: (1) uniform density from coronal to the apical aspect, (2) no voids, (3) level of root canal filling 0–2 mm from the radiographic apex, and (4) tapered. While unacceptable RCT comprises followings: (1) overfilling: root filling extending beyond the radiographic apex, (2) underfilling: root filling ending =2 mm short of the radiographic apex, and (3) inadequate density: root filling with visible voids in the filling mass or between the filling mass and root canal walls on the final radiograph.
Teeth with incomplete treatment, missing preoperative or postoperative periapical radiographs, poor quality radiographs, or showing <2 mm of the periapical region and radiographs that did not allow proper evaluation due to superimposition of an anatomical structure were excluded from the study.
Data were analyzed using SPSS software (SPSS version 22.0, SPS SPSS, Chicago, IL, USA). Frequency and percentages were reported for categorical variables, whereas mean and standard deviation for continuous variables. Chi-square test was used to report any difference with respect to acceptable and not acceptable RCT outcomes. Logistic regression was run to report predictors of unacceptable RCT. Odds ratio, adjusted odds ratio, and 95% confidence interval (CI) were reported. P = 0.05 and less are considered as statistically significant.
| Results|| |
The distribution of variables with respect to the quality of RCT is summarized in [Table 1]. Of 306 collected samples of endodontically treated teeth, 169 were female, and 137 were male, and 69.9% were of age 43 and below. The total number of The total number of RCT done in the anterior teeth was 116 and 190 in the posterior teeth, mostly in the maxilla (66%). Asymptomatic irreversible pulpitis was diagnosed in 84 (27.5%) tooth, symptomatic irreversible pulpitis in 75 (24.5%), and necrosis in 56 (18.3%). Moreover, 52.9% of the teeth had healthy apical tissue, while 33.0% had asymptomatic apical periodontitis. A total of 196 (64.1%) teeth had a single root canal. Moreover, 214 (69.9%) of the RCTs had acceptable quality. Chi-square test was run to see the difference between acceptable and unacceptable RCT, and no difference was found with respect to age, gender, number of canals treated, position and location of the tooth, pulpal diagnosis and the year of treatment. However, teeth with healthy apical tissues had significantly more acceptable RCT compared to those with periapical periodontitis and abscess with P = 0.007 [Table 1].
|Table 1: Distribution of variables with respect to quality of root canal treatment (n=306)|
Click here to view
Regarding the reasons for unacceptable RCTs, 92 (30.07%) were unacceptable, 5.2% were overfilled, 13.7% were underfilled, 9.5% had voids, and 1.6% mishaps were reported. Logistic regression was run to evaluate the predictors of unacceptable RCTs, and it was found that the female gender had 1.7 times higher odds of unacceptable RCTs compared to males, and the association was significant with 95% CI: 1.02–2.87. Teeth with abscess and periapical periodontitis had 2.11 times higher odds of unacceptable RCTs compared to teeth with normal periapical radiographs, and the association was significant with 95% CI: 1.27–3.50 after adjusting the age, number of canals, tooth position and location [Table 2].
| Discussion|| |
It is of pivotal importance to assess the quality of hands-on training provided by the university by observing and investigating the treatments performed by the students. The present study was aimed to evaluate the quality of endodontic treatments by evaluating periapical radiographs taken during and after the RCT procedures. Radiographical assessment imposes a considerable degree of variation related to a subjective analysis by the dentist; hence, to reduce any inter- and intra-examiner discrepancy in our study, the diagnosis criteria were kept strictly defined, and all investigators were calibrated before making any assessment. It has been reported that significant variations could exist between investigators regarding the assessment of the quality of RCTs; hence globally acceptable criteria for reporting acceptable and unacceptable quality of RCT approved by the European Society of Endodontology were used similar to Kielbassa et al.,
Studies conducted globally that evaluate the quality of RCTs performed by undergraduate students showed a wide variation of the frequency of acceptable fillings.,,,,, The results of the current study showed an acceptable RCT (69.9%). These findings are in line with the findings of the study conducted in Taibah University, Saudi Arabia, comparatively higher than other study conducted in Iran and Saudi Arabia, and less compared to the study conducted previously in Ireland among undergraduate students of Cork University School and Hospital. The variation in the quality of RCT could be related to differences in diagnosis criteria, variation among assessors, the difference in comparison groups (year of study), for example, a study conducted by Abdulrab et al. Compared the quality of quality of RCT done by 5th and 6th level undergraduates of two Saudi University “King Khalid University, Abha, and Alfarabi Dental College, Riyadh,” whereas AlRahabi et al. compared the quality of RCT done by 4th and 5th level undergraduates of Taibah University. Moreover, Abdulrab et al. used self-reported errors using a questionnaire and that could lead to reporting or recall bias and explains variation in the findings.
However, in the current study to reduce the rates of biases due to recall and reporting, the radiographic evaluation was done, and moreover, dentists were trained for the assessment using the diagnosis criteria, and therefore, the chances of wide variation (radiographic diagnostic mistakes) were taken into account before the conduct of the study. Despite that, the result should be evaluated with caution, as the radiographic assessment has some inherent drawbacks; for example, all procedural errors are not visible. Different techniques and angles are used for taking radiographs, for example, bisecting angle versus parallel angle, and even that could lead to differences in the quality of radiographs and can lead to variation in the assessment.,
The present study reported a comparatively low level of low-quality RCT delivered by female undergraduates, but still, the ratio is reasonably higher, and this could be explained by insufficient time allocation for training undergrads, lack of timely audit, and evaluation methods.,,, Apparently, upgrading the time dispensed to clinical training and expanding staff-to-student interaction proportions can enhance the quality of RCTs performed by undergraduate students. Despite the higher percentage of acceptable fillings in the present study in comparison to other studies, there should be plans to revise both the preclinical and clinical curriculum of endodontic in the near future to fulfill the acceptable standards. Timely audits should be conducted, and surveys aiming to highlight and understand the problems and difficulties faced by undergraduates during clinical hours should be conducted to improve the current practices.
Clinical relevance of the above study will let us know the technical quality and frequency of complications in RCTs performed by undergraduate dental students, which helps to improve the treatment quality. The results of this study should be interpreted with caution because of the following limitations: first, the study was based on a single center, therefore, results could not be generalized; second, the sample size was small, however, stringent methodology and reporting have been used; and third, procedure error could not be identified, and this could have overestimated the rates of acceptable quality. In this study, we selected very stringent criteria for assessing the quality of RCTs; further studies with a larger sample size and with a broader definition of radiographic acceptable and unacceptable RCTs should be conducted. Moreover, teaching methods, curriculum, and preclinical and clinical mentoring vary from one institution to others, therefore, it is recommended to conduct multicenter studies.
| Conclusion|| |
The quality of the root canal filling performed by undergraduate dental students was acceptable. The most frequent error was underfill of the root canal obturation. Rate of unacceptable RTCs is low with respect to other studies but reasonably higher, and therefore, auditing of RCTs done by undergraduates should be done routinely and discussed to improve the student's clinical skills for the long-term outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J 2006;39:921-30.
Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent 2016;10:144-7.
] [Full text]
Kim Y, Lee D, Kim DV, Kim SY. Analysis of cause of endodontic failure of c-shaped root canals. Scanning 2018;2018:1-7.
Donnelly A, Coffey D, Duncan HF. A re-audit of the technical quality of undergraduate root canal treatment after the introduction of new technology and teaching practices. Int Endod J 2017;50:941-50.
Ribeiro DM, Réus JC, Felippe WT, Pacheco-Pereira C, Dutra KL, Santos JN, et al
. Technical quality of root canal treatment performed by undergraduate students using hand instrumentation: A meta-analysis. Int Endod J 2018;51:269-83.
Polyzos NK, Sarris KG, Pita AI, Mikrogeorgis GV, Lyroudia KM. Quality of root canal fillings performed by undergraduate students and the related factors on the treatment outcome: A 2- to 5-year follow-Up. Eur Endod J 2018;3:179-85.
Saatchi M, Mohammadi G, Vali Sichani A, Moshkforoush S. Technical quality of root canal treatment performed by undergraduate clinical students of Isfahan dental school. Iran Endod J 2018;13:88-93.
Abdulrab S, Alaajam W, Al-Sabri F, Doumani M, Maleh K, Alshehri F, et al
. Endodontic procedural errors by students in two Saudi dental schools. Eur Endod J 2018;3:186-91.
Alhekeir DF, AlSarhan 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]
Eleftheriadis GI, Lambrianidis TP. Technical quality of root canal treatment and detection of iatrogenic errors in an undergraduate dental clinic. Int Endod J 2005;38:725-34.
Kielbassa AM, Frank W, Madaus T. Radiologic assessment of quality of root canal fillings and periapical status in an Austrian subpopulation-An observational study. PLoS One 2017;12:e0176724.
AlRahabi MK. Evaluation of complications of root canal treatment performed by undergraduate dental students. Libyan J Med 2017;12:1-6.
Lynch CD, Burke FM. Quality of root canal fillings performed by undergraduate dental students on single-rooted teeth. Eur J Dent Educ 2006;10:67-72.
Balto H, Al Khalifah Sh, Al Mugairin S, Al Deeb M, Al-Madi E. Technical quality of root fillings performed by undergraduate students in Saudi Arabia. Int Endod J 2010;43:292-300.
Khabbaz MG, Protogerou E, Douka E. Radiographic quality of root fillings performed by undergraduate students. Int Endod J 2010;43:499-508.
Alsulaimani RS, Al-Manei KK, A Alsubait S, AlAqeely RS, A M Al-Shehri S, M Al-Madi E. Effects of Clinical Training and Case Difficulty on the Radiographic Quality of Root Canal Fillings Performed by Dental Students in Saudi Arabia. Iran Endod J 2015;10:268-73.
Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: Systematic review of the literature-Part 1. Effects of study characteristics on probability of success. Int Endod J 2007;40:921-39.
Lazarski MP, Walker WA 3rd
, Flores CM, Schindler WG, Hargreaves KM. Epidemiological evaluation of the outcomes of nonsurgical root canal treatment in a large cohort of insured dental patients. J Endod 2001;27:791-6.
[Table 1], [Table 2]