|Year : 2021 | Volume
| Issue : 2 | Page : 154-161
Treatment concepts for restorations of endodontically treated teeth: Survey of dentists in Jeddah city, Saudi Arabia
Mohammed Zahran1, Mona El-Madhoun2, Samaa Redwan3, Khalid Merdad4, Helal Sonbul5, Dania Sabbahi6
1 Department of Oral and Maxillofacial Prosthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Orchid Dental Clinic, Sabah Center, Jeddah, Saudi Arabia
3 Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
4 Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
5 Department of Restorative Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
6 Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Submission||27-Jun-2020|
|Date of Decision||14-Aug-2020|
|Date of Acceptance||25-Aug-2020|
|Date of Web Publication||8-May-2021|
Dr. Mohammed Zahran
4327 King Abdulaziz Road, Almuhamdiah District, P.O. Box: 126543, Jeddah 21352
Source of Support: None, Conflict of Interest: None
Introduction: Practices followed by dentists for restoring endodontically treated teeth (ETT) vary with a variety of available techniques and materials for post- and-core restorations. The aim of this study was to identify concepts for restoring ETT among dentists in Jeddah, Saudi Arabia.
Materials and Methods: A two-section questionnaire was developed using online web-based application (Google forms) and sent to 400 dentists. The first section collected demographic information and the second section concerned about the treatment concept and materials for restoring ETT. Descriptive statistics were used to analyze the data, followed by Chi-square or Fisher's exact test to compare the responses to different questions among general dentists and specialists/consultants.
Results: A total of 138 questionnaires were completed. Most of the participants reported a frequently or always use of extracoronal restoration in anteriors (55.1%), premolars (89.1%) and 88.4% for molars. Participant reported frequent placement of posts in anteriors (56.5%), premolars (84.1%) and 64.5% for molars. Nonmetallic post and cast post and core were the preferred option for anteriors and molars, while responses were equally divided between nonmetallic post and cast post and core for premolars. Composite resin was the preferred core material for all teeth.
Conclusions: The use of endodontic posts, composite resin as a core and extracoronal restoration for restoring ETT is common among participants. Some of the concepts expressed by the participants are outdated and does not coincide with the evidence-based practice.
Keywords: Coronal restoration, dental cement, endodontically treated teeth, post and core technique, survey
|How to cite this article:|
Zahran M, El-Madhoun M, Redwan S, Merdad K, Sonbul H, Sabbahi D. Treatment concepts for restorations of endodontically treated teeth: Survey of dentists in Jeddah city, Saudi Arabia. Saudi Endod J 2021;11:154-61
|How to cite this URL:|
Zahran M, El-Madhoun M, Redwan S, Merdad K, Sonbul H, Sabbahi D. Treatment concepts for restorations of endodontically treated teeth: Survey of dentists in Jeddah city, Saudi Arabia. Saudi Endod J [serial online] 2021 [cited 2021 Jun 16];11:154-61. Available from: https://www.saudiendodj.com/text.asp?2021/11/2/154/315642
| Introduction|| |
The goal of restoring endodontically treated teeth(ETT) is to restore esthetics, phonetic, and function. Restoring ETT requires two additional goals which are providing coronal seal and protection against fracture, which necessitate conserve the natural tooth structure. The survival of ETT is affected by many factors. It is well known that failure of ETT is more likely due to restoration failure than endodontic treatment itself.
Ray and Trope evaluated the effect of the quality of the coronal restoration and root canal obturation on the radiographic periapical status. They concluded that the quality of coronal restoration was significantly more important than the quality for endodontic treatment for the healing of apical periodontitis. Therefore, the final restoration of ETT is of very crucial for a successful outcome.
The amount of remaining tooth structure would dictate the options of final restoration and that would be different regarding anterior versus posterior teeth. Despite the fact the post is used to retain the core, the decision-making regarding the need of post placement, type of post (postdesign), and postmaterial is controversial.
Dentists are challenged with the increasing number of ETT needed to be restored and with a growing inventory of different materials designed for restoring them. Scientific literature contains many studies which investigated the restoration of ETT. Unfortunately, these studies are mostly in vitro and material-oriented and performance of materials in these studies might not reflect the real clinical performance., In addition, literature lacks of well-designed clinical trials that answers different questions concerning restoration of ETT., Hence, it is expected that the materials and techniques that are used in restoring ETT does not always reflect the best available scientific evidence. Dentists' choices of materials and techniques will be influenced by their knowledge level, years of experience, availability of materials, and clinician preference. Thus, collecting data regarding the dentists' practices and preferences for restoring ETT through surveys will help in understanding the current pattern, which will guide the dental curricula, continuous education courses, and future research interest. Therefore, the aim of the present study was to investigate the concepts, techniques, and materials used in restoring ETT by the dentists in Jeddah, Saudi Arabia, and the influence of level of specialization on the dentists' choices.
| Materials and Methods|| |
The study protocol was approved by Ethical Committee at King Abdulaziz University, Faculty of Dentistry (#004-01-17) and all procedures performed were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
A self-administrated questionnaire was developed in English to identify the treatment concepts for restoration of ETT. The questionnaire was developed using previous surveys conducted in other parts of the world.,,,,,,
The developed questionnaire consisted of two sections: the first section collected demographic information and the second section concerned about the treatment concept and materials for restoring ETT. Two of these questions were conceptual and focused on the ferrule concept and the reason for postplacement. The rest of the questions asked about the preferred restorative option (direct or extracoronal), posttype (prefabricated metallic, prefabricated nonmetallic or cast post and core), core type (amalgam, composite resin, glass ionomer, or compomer), and luting cement type (zinc phosphate, zinc polycarboxylate, glass ionomer, resin, or other). Most of the questions were built on Likert scale (never, rarely, frequently, and always). Majority of the responses were collected taking in consideration the tooth position (anterior, premolar, or molar). All questions will be presented in the result section to avoid repetition. The face validity of the questionnaire was established by three experts in the fields of prosthodontic, restorative dentistry, and endodontics.
The research population was inclusive of general practitioners and residents, specialists or consultants in the field of prosthodontics, restorative dentistry and advance general dentistry.
Two of the authors visited four major governmental hospitals in Jeddah, Saudi Arabia: King Abdulaziz University Dental Hospital, King Fahad hospital-North Dental Center, King Fahad Armed Force Hospital and King Abdulaziz Medical City (National Guard Hospital). Staff in these hospitals were approached to participate and asked to fill the questionnaire electronically using a provided hand-held device. The questionnaire was administrated using Google forms (Alphabet Co., Mountain View, CA) online web-based application. All participants were consented electronically before filling the online questionnaire. In addition, the questionnaire link was distributed to the Restorative Dentistry and Prosthodontics residency program directors in Jeddah to be distributed to the residents. Furthermore, the link was distributed by sending massages to a network of prosthodontists using the instant messaging software WhatsApp (WhatsApp Inc., Mountain View, California, USA).
Data was collected, tabulated, and statistically analyzed to estimate descriptive statistics (frequencies and percentages). Chi-square or Fisher's exact test was used to compare the responses to different questions among general dentists and specialists or consultants. All statistical analyses were conducted using IBM Statistical Package for Social Science for Windows (SPSS, Version 23, SPSS Inc., IBM, Somers, New York, NY, USA) at a significance level of (0.05).
| Results|| |
A total 400 potential participants were approached and invited to fill the questionnaire and 138 of them agreed to participate and completed the questionnaire, with a response rate of (34.8%). The responders included (n = 45, 32.6%) general dentists and (n = 93, 67.4%) specialist\consultants and about 53% of them were male. The majority of the dentists who filled the questionnaire have more than 10 years of experience (43.5%) and about 33% of them reported that they have restored 10–50 ETT during the last 12 months [Table 1].
Out of the total 138 dentists, majority of the participants (81.2%) believe that lowering the level of the finish line apically below the core foundation increases the fracture resistance, while 10.1% believe that it does not increase the fracture resistance, and 8.7% are not sure.
More than 60% of the general dentists and specialists/consultants reported that they frequently to always restore anterior teeth with direct restorations. Similar percentages (about 40%) of the participants stated that they frequently to always place direct restorations in premolars and molars, while majority of them (about 89%) stated that they frequently to always place extracoronal restorations in premolars and molars. Responses to questions regarding the type of restorations placed in ETT can be seen in [Table 2].
|Table 2: Responses to the question on the frequency of restoring endodontically treated teeth with direct restoration (e.g., composite or amalgam) or extracoronal restoration (e.g., crown)|
Click here to view
When the dentists were asked about the reason for postplacement in ETT, almost all the dentists believed that the reason is to retain the core (93.5%), and many of them stated that the reason for post placement is to reinforce the tooth structure and reduces the fracture probability (23.3%) [Table 3].
|Table 3: Responses to the question on the reason for placing a post in endodontically treated teeth|
Click here to view
Most of participants reported that they frequently place a post in endodontically treated anterior teeth (50.7%), premolars (55.8%), and molars (47.1%). Responses to the question regarding the frequency of postplacement in ETT can be seen in [Table 4].
|Table 4: Responses to the question on the frequency of postplacement in an endodontically treated teeth|
Click here to view
Regarding the appropriate time for postplacement after root canal treatment, most of the responses were almost equally divided between immediately after obturation (31.2%), 48 h after obturation (31.2%) and 1–2 weeks after obturation (26.8%), while only 10.9% said that it does not matter.
About 2/3 of the participants reported that they frequently to always place nonmetallic prefabricated post in anterior teeth and premolars, while 63% of them reported that they rarely to never place them in molars. More than half of the participants reported that they frequently to always place cast post and core for anterior teeth (58%), premolars (69.9%) and molars (54.3%). Responses to the question regarding the type post preference for restoring ETT can be seen in [Table 5].
|Table 5: Responses to the question on the frequency of using different type of posts|
Click here to view
The participants in this study stated that they frequently to always preferred to use composite resin as a core buildup material in anterior teeth (92%), premolars (85%), and molars (78%). Responses to the question regarding the usage of different core buildup for ETT can be seen in [Table 6].
|Table 6: Responses to the question on the frequency of using different core buildup materials|
Click here to view
More than three-fourth of participants indicated that they cement the nonmetallic prefabricated post with resin cement (82%) followed by glass ionomer cement (8.7%). About 33% of the participants indicated that they cement metallic prefabricated posts with resin cement followed by glass ionomer for 31% of the participants. Forty-eight of participants (34.8%) use glass ionomer cement for cast post and core, followed by resin cement (30.4%). Responses to the question regarding the cement preference for cementing different type of posts can be seen in [Table 7].
|Table 7: Responses to the question on the cement type with each posttype|
Click here to view
| Discussion|| |
The present study has provided information about the current treatment concept, techniques, and materials used in restoring ETT by the general dentists and specialists in Jeddah city of Saudi Arabia with a special focus on the tooth position (anterior, premolar, or molar) as a factor that might influence the decision making.
Ferrule effect is considered an important factor for preventing failures of ETT. Lowering the level of the finish line 1–2 mm apically below the core foundation in an ETT increases the fracture resistance. In the present study, 81.2% of the participants held this belief. This figure is in line with other investigations in Germany and Saudi Arabia where between 78% and 88% of the participants held the same belief,,, and in contrast to a study in Sweden, in which 44%–53% of the participants held this belief. It has to be emphasized that about 13% of the specialists/consultants and 31% of the general dentists failed to recognize the importance of ferrule for improving the fracture resistance although this is considered as a basic knowledge. This knowledge gap should receive a significant attention in designing a continuous education courses in the future.
When asked about the frequency of restoring anterior teeth using direct or extracoronal restorations, participants were divided between direct and extracoronal restorations. Previous studies showed survival rate above 90% for direct composite restorations retained using nonmetallic posts.,, Responses of general dentists were similar to specialists/consultants in relation to direct restoration, but not for the extracoronal restoration. Higher percentage of the specialists/consultants indicated that they prefer to place extracoronal restorations for anterior teeth in comparison to general dentists, 63.2%–40%, respectively. This could be explained by the difference between the pool of cases seen by specialists/consultants and general dentists, as the former are expected to see complex, esthetically demanding and structurally compromised cases which might require full coverage restorations. A recent survey evaluated the preferences of undergraduate students and newly graduate dentists in Saudi Arabia toward direct and extracoronal restorations as a restorative option for anterior ETT. More than 90% of participants in the survey chose direct restorations for teeth with <50% loss of coronal tooth structure and extracoronal restorations for teeth with more than 50% loss of coronal tooth structure.
Responses to the frequency of using direct and extracoronal restorations for premolars and molars showed preference toward extracoronal restorations. This is in agreement with expected reduction in the strength of the tooth structure with endodontic access cavity opening, caries and restorative procedures which require occlusal coverage to protect the remaining tooth structure.,,,
In the present study, only 31% of the participants stated that they tend to place the postimmediately after obturation. This is contradicting with the obvious advantages of immediate postplacement following obturation including greater familiarity with the root canal morphology and its working length and less risk of coronal tooth tissue fracture and loss of reference point, which leads to better control over the amount of gutta-percha removal and less risk of root canal perforation.
In the present study, the majority of participants (93.5%) believed that the purpose of postplacement is to retain the core This percentage is similar to previous studies in United Kingdom and Sweden,,, and in contrast to other studies in Germany, Kuwait and Saudi Arabia in which a higher percentages were reported.,,, Surprisingly, 23.2% of the participants stated that they believe that post placement will reinforce the tooth structure. This is in contrast to the general believe that placement of post does not enforce the tooth structure.,, It is worth mentioning that about 35% of general dentists and 17% of the specialists/consultants shared this believe. This misconception should receive a special attention during the future continues education courses.
It was apparent that most of the participants always to frequently place a post in ETT regardless of the tooth position. This finding is in agreement with previous reports from Sweden and Saudi Arabia., Comparing general dentists to specialists/consultants' responses revealed a statistically significant tendency for post placement among specialists/consultants when restoring anterior teeth or premolars. It has to be stressed that the decision of post placement requires visualization of the remaining tooth structure after preparation which might need an initial preparation of the involved tooth. Specialists/consultants are expected to have better ability in visualizing the remaining tooth structure after preparation, thus they might tend to place post more frequently. In contrast, specialists/consultants reported lower tendency to place post in molars when compared to general dentists. This is could be due to the better experience and knowledge among specialists and consultants with the innovative conservative approaches in restoring ETT (e.g., utilizing pulp chamber for core retention and using intracoronal direct and indirect restorations with cuspal coverage).,,
In regard to the posttype, nonmetallic prefabricated post was the first choice for anterior teeth and molars followed by cast post and core. The use of cast post and core in anterior teeth might interfere with the current trend of utilizing all-ceramic restorations for anterior teeth. When asked about the frequency of utilizing different type of posts for premolars, participants showed equal tendency for nonmetallic prefabricated post and cast post and core. Findings from previous studies are controversial. With some studies, in Germany and Saudi, Arabia favored nonmetallic prefabricated glass-fiber,,, and other studies, in Sweden, United States, and United Kingdom, favored cast post and core.,, These controversies could be attributed to the continuous changes in the trends in dentistry throughout the years as a result of the developments in the field of dental materials and new findings from in vitro and clinical studies.
Majority of participants stated that they frequently to always use composite resin as a core buildup for ETT. This is in agreement with previous studies in Germany and Saudi Arabia.,, On the other hand, the participants in the present study reported that they frequently use amalgam as a core buildup material in restoring endodontically treated molars. This is in contrast to a previous study in Germany and in agreement with previous studies in the United States and United Kingdom., This inclination toward the use of amalgam is expected to decline in the near future as a result of the Saudi Arabia recent commitment in Minamata Convention to phasing out mercury containing product.
The majority of participants use resin cement for cementation of nonmetallic prefabricated post, while for metallic prefabricated post and cast post and core they use glass ionomer cement, followed by composite resin cement. Previous studies differ in regard to the type of cement used. Two studies in United States and Saudi Arabia favoring the glass ionomer cement,, while one study in Saudi Arabia favoring the use of resin cement. The use of glass ionomer with nonmetallic prefabricated post interferes with the need of proper bonding of the post with the root dentin to achieve mechanically homogeneous units “monoblock,” which improves the stress distribution within the root and provides better sealing ability for better clinical outcomes.,
It has to be emphasized that comparing the results of the present study to previous studies should be perused with caution, as practices and material selections might be influenced by the geographic region and the trends changes in dentistry as a result of evolutionary advancement in relation to dental materials and body of the dental literature over the years. In addition, the differences in the responses between general dentists and specialists/consultants can be attributed to the differences in the experience. About 60% of the specialists/consultants had more than 10 years of experience in comparison to about 9% of the general dentists. In addition, 58% of the specialists/consultants restored more than 50 ETT during the past 12 months in comparison to 40% of the general dentists.
This study has some limitations. The survey was based on self-administrated closed-ended questions and the results might be affected by the inherited limitations of self-administrated questionnaires, including recall bias, providing ideal answers that do not reflect the real practice and providing answers based on different understanding and interpretation of the questions. Alternatively, collecting data via face-to-face interview through structured questionnaire might provide valuable data as it allows for discussion and provide insight on the rationale for different answers provided by the participants.
The questionnaire in the present study focused on gathering data regarding the common practice followed by participants and did not assess the decision-making ability. This could be the aim for a future study, in which the decision-making ability of the dentists can be assessed using structured hypothetical scenarios. The current study can be the nidus for a nation-wide dental practice-based research aiming to assess the common practices and material selections followed by dentists and link them to different clinical outcomes.
| Conclusions|| |
The practical use of endodontic posts, composite resin as a core foundation and extracoronal restoration for restoring ETT is common among participating dentists in this study. This survey shed the light on certain misconception and knowledge gap among the participants. These misconceptions should be stressed in the dental curricula and continuous education courses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic treatment outcomes. Dent Clin North Am 2017;61:59-80.
Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related to extraction of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e31-5.
Heling I, Gorfil C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I. Endodontic failure caused by inadequate restorative procedures: Review and treatment recommendations. J Prosthet Dent 2002;87:674-8.
Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 1995;28:12-8.
Aurélio IL, Fraga S, Rippe MP, Valandro LF. Are posts necessary for the restoration of root filled teeth with limited tissue loss? A structured review of laboratory and clinical studies. Int Endod J 2016;49:827-35.
Baba NZ, Goodacre CJ. Restoration of endodontically treated teeth: Contemporary concepts and future perspectives. Endod Top 2014;31:68-83.
Naumann M, Neuhaus KW, Kölpin M, Seemann R. Why, when, and how general practitioners restore endodontically treated teeth: A representative survey in Germany. Clin Oral Investig 2016;20:253-9.
Habib SR, Al Rifaiy MQ, Alkunain J, Alhasan M, Albahrani J. Concepts of restoring endodontically treated teeth among dentists in Saudi Arabia. Saudi J Dent Res 2014;5:15-20.
Naumann M, Schmitter M, Krastl G. Postendodontic restoration: Endodontic post-and-core or no post at all? J Adhes Dent 2018;20:19-24.
Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: A literature review. J Endod 2004;30:289-301.
Akbar I. Knowledge, attitudes and practice of restoring endodontically treated teeth by dentists in North of Saudi Arabia. Int J Health Sci (Qassim) 2015;9:41-9.
Sarkis-Onofre R, Pereira-Cenci T, Opdam NJ, Demarco FF. Preference for using posts to restore endodontically treated teeth: Findings from a survey with dentists. Braz Oral Res 2015;29:1-6.
Eckerbom M, Magnusson T. Restoring endodontically treated teeth: A survey of current opinions among board-certified prosthodontists and general dental practitioners in Sweden. Int J Prosthodont 2001;14:245-9.
Alenzi A, Samran A, Samran A, Nassani MZ, Naseem M, Khurshid Z, et al
. Restoration strategies of endodontically treated teeth among dental practitioners in Saudi Arabia. A nationwide pilot survey. Dent J (Basel) 2018;6:44.
Morgano SM, Bowley JF, Thalib L, Abdulkarim E. A survey of contemporary philosophies and techniques of restoring endodontically treated teeth in Kuwait. Med Princ Pract 2001;10:14-22.
Naumann M, Schmitter M, Frankenberger R, Krastl G. Ferrule comes first. Post is second! fake news and alternative facts? A systematic review. J Endod 2018;44:212-9.
Cerny D, Eckert S, Mounajjed R. Retrospective 9-year clinical outcome report on adhesive post-endodontic treatment of anterior teeth using prefabricated fiber posts. Int J Prosthodont 2018;32:14-6.
Grandini S, Goracci C, Tay FR, Grandini R, Ferrari M. Clinical evaluation of the use of fiber posts and direct resin restorations for endodontically treated teeth. Int J Prosthodont 2005;18:399-404.
Piovesan EM, Demarco FF, Cenci MS, Pereira-Cenci T. Survival rates of endodontically treated teeth restored with fiber-reinforced custom posts and cores: A 97-month study. Int J Prosthodont 2007;20:633-9.
Alzain S. A survey on restorative methods to rehabilitate endodontically treated anterior teeth by dental students and new graduates of king saud university. Saudi Endod J 2018;8:176-82. [Full text]
Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for the restoration of endodontically treated teeth: A systematic review of the literature--Part 1. Composition and micro and macrostructure alterations. Quintessence Int (Berl) 2007;38:733-43.
Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod 1989;15:512-6.
Pantvisai P, Messer HH. Cuspal deflection in molars in relation to endodontic and restorative procedures. J Endod 1995;21:57-61.
Soares CJ, de Paula Rodrigues M, Faria-E-Silva AL, Santos-Filho PC, Veríssimo C, Kim HC, et al
. How biomechanics can affect the endodontic treated teeth and their restorative procedures? Bra Oral Res 2018;32:169-83.
Ricketts DN, Tait CM, Higgins AJ. Tooth preparation for post-retained restorations. Br Dent J 2005;198:463-71.
Brunton PA, Sharif MO, Creanor S, Burke FJ, Wilson NH. Contemporary dental practice in the UK in 2008: Indirect restorations and fixed prosthodontics. Br Dent J 2012;212:115-9.
Hussey DL, Killough SA. A survey of general dental practitioners approach to the restoration of root-filled teeth. Int Endod J 1995;28:91-4.
Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in endodontically treated teeth. J Endod 2010;36:609-17.
Dias MC, Martins JN, Chen A, Quaresma SA, Luís H, Caramês J. Prognosis of indirect composite resin cuspal coverage on endodontically treated premolars and molars: An i prospective study. J Prosthodont 2018;27:598-604.
Rocca GT, Krejci I. Crown and post-free adhesive restorations for endodontically treated posterior teeth: From direct composite to endocrowns. Eur J Esthet Dent 2013;8:156-79.
de Carvalho MA, Lazari PC, Gresnigt M, Del Bel Cury AA, Magne P. Current options concerning the endodontically-treated teeth restoration with the adhesive approach. Bra Oral Res 2018;32:147-58.
Morgano SM, Hashem AF, Fotoohi K, Rose L. A nationwide survey of contemporary philosophies and techniques of restoring endodontically treated teeth. J Prosthet Dent 1994;72:259-67.
Almohareb T. Sealing ability of esthetic post and core systems. J Contemp Dent Pract 2017;18:627-32.
Tay FR, Pashley DH. Monoblocks in root canals: A hypothetical or a tangible goal. J Endod 2007;33:391-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]