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Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 202-213

Awareness and endodontic clinical practice of the general dental practitioners in Albaha region

1 Restorative Dental Science Department, Albaha University, Albaha, Saudi Arabia
2 Dental Health Department, Albaha University, Albaha, Saudi Arabia
3 Albaha Dental Center, MOH, Albaha, Saudi Arabia
4 Psychology Department, Albaha University, Albaha, Saudi Arabia

Date of Submission15-Apr-2020
Date of Decision09-May-2020
Date of Acceptance17-Jun-2020
Date of Web Publication8-May-2021

Correspondence Address:
Dr. Mohammed Serhan A. Alserhan
Department of Endodontics, Albaha University, Albaha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_81_20

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Introduction: This study aimed to investigate the awareness and clinical practice of the general dental practitioners (GDPs) regarding endodontic treatment in Albaha region, Saudi Arabia.
Materials and Methods: An e-questionnaire was distributed among the GDPs in Albaha Province. The e-questionnaire was composed of 21 questions that assessed the awareness and the clinical practice of the GDPs regarding endodontic treatment. The data were collected and statistically analyzed.
Results: Fifty-seven (81.42%) out of 70 GDPs responded to the distributed e-questionnaire. Most of the respondents were practicing endodontics on molars (82.4%). A significant difference was observed in performing retreatment between the practitioners who worked in the private sector than peers who worked in the governmental sector (P = 0.015). Noticeably, almost 60% of the participated dentists were not using rubber dam isolation regularly for endodontic procedures. Furthermore, only about 50% of them used cold test for pulpal diagnosis, while 3.5% used electric pulp tester. Few were using intracanal medicament and follow the patients after completing the treatment.
Conclusions: A clear deficiency in some aspects of the awareness and clinical endodontic practice of the GDPs in Albaha region was observed. The international and national guidelines of endodontic practice should be implemented.

Keywords: Awareness, endodontic practice, general dentist, knowledge, Saudi Arabia

How to cite this article:
Alserhan MA, Alzahrani AH, Alzahrani AS, Alzahrani SS. Awareness and endodontic clinical practice of the general dental practitioners in Albaha region. Saudi Endod J 2021;11:202-13

How to cite this URL:
Alserhan MA, Alzahrani AH, Alzahrani AS, Alzahrani SS. Awareness and endodontic clinical practice of the general dental practitioners in Albaha region. Saudi Endod J [serial online] 2021 [cited 2021 Jun 17];11:202-13. Available from: https://www.saudiendodj.com/text.asp?2021/11/2/202/315655

  Introduction Top

The endodontic treatment's primary objective is to preserve the natural teeth with health status and acceptable function. Furthermore, outcomes of the root canal treatment are affected by variable prognostic factors.[1] One of the most important prognostic factors are the dentist-related factors which include the level of canals disinfection, the quality of coronal and radicular fillings, procedure mishaps, and the use of innovative endodontic technologies by the dentists according to their skills and knowledge.[1],[2]

Therefore, to confirm adequate root canal treatment outcomes, endodontic clinical practice and undergraduate curriculum guidelines have been issued by governmental health services and endodontic societies.[3],[4],[5] Furthermore, numerous researches have been conducted to investigate the compliance of dental practitioners in the implementation of these guidelines.[6],[7],[8],[9] Unfortunately, these researches show the unpredictable compliance of the practitioners with endodontic guidelines.

In consequence, the failure rate of the root canal treatment performed by the general dental practitioners (GDPs) is higher than previously reported in general practice.[10],[11],[12] This variability in the outcomes may reflect a difference in the technical quality of the root canal treatment performed.

Several studies have investigated the variable aspects of the endodontic practice performed by the GDPs at national or international levels.[6],[7],[8],[9] However, to the best of our knowledge, no such study had been conducted in Albaha region. Therefore, this study aims to investigate the awareness and clinical practice of the GDPs regarding endodontic treatment protocols in Albaha region.

  Materials and Methods Top

This study was approved by the Ethics Committee of the Education, Training Center and Academic Affairs at the Saudi Ministry of Health “Albaha branch” (approval number 091019).

A Google Forms e-questionnaire was designed as a modified version of the e-questionnaire that was developed by Bogari et al. in 2019.[8] The e-questionnaire was composed of 6 demographic items and 21 questions that assessed six items related to the clinical endodontic practice of GDPs in Albaha region. The e-questionnaire link was distributed among GDPs as a text message. The title and the purpose of the conducted study were included in the e-questionnaire. Furthermore, the agreement consent of the participants was included in the e-questionnaire. The answers “data” were tabulated in an Excel sheet and statistically analyzed using SPSS version 22 (Armonk, New York, USA). A Chi-square test was used to evaluate the relationship between categorical variables, where P < 0.05 was taken to indicate statistical significance.

  Results Top

A total of 57 GDPs (81.42%) out of 70 in Albaha region responded to the distributed e-questionnaire. Among the total respondents, 47.4% were graduated from governmental schools and 52.6% from private schools. Most of the participants (61%) were of experience <5 years. The demographic information of the participants is presented in [Table 1].
Table 1: Demographic characteristics of the participants

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Case difficulty assessment

The findings of this study showed that the majority of the GDPs did root canal treatment on molars (n = 47, 82.45%). The nationality and working sector were the only demographic characteristics that had significant effects on the performance, P = 0.29 and 0.048, respectively.

Moreover, a significant difference was observed in performing retreatment between the GDPs who worked in the private sector than peers who worked in the governmental sector (57.89% vs. 39.47%; P = 0.015). Yet, almost half of the GDPs reported that they retreated failing cases regularly (n = 26, 45.6%).

It is noteworthy that 42.85% of the non-Saudi participants and 40.9% of those who have experienced more than 5 years are less likely to refer cases to the endodontist. The difference was significant for both P = 0.048 and 0.045, respectively. [Table 2] summarizes the case difficulty assessment.
Table 2: Case difficulty assessment responses

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Patient's safety and infection control

The results of this study revealed a clear variation in the implementation of patient's safety and infection control protocol. In this respect, only 28.07% of the participating practitioners take consent form before the procedure. Significantly, the non-Saudi GDPs and those with more than 5 years' experience were more frequently obtaining consent form than other peers (P = 0.12 and 0.034, respectively).

The majority of the respondents (78.9%) take full medical history for their patients. Only 40.3% of the respondents use the rubber dam isolation regularly.

Most of the respondents (87.71%) consider changing handpiece after each patient as part of the dental practice policy. [Table 3] describes the GDPs' practices in relation to patient's safety and infection control.
Table 3: Patient's safety and infection control general dental practitioners' responses

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49.12% of the participants regularly use the cold test for pulpal diagnosis, while 3.5% of them use the electric pulp tester (EPT) for pulp diagnosis.

75.43% of the practitioners take preoperative radiographs. [Table 4] describes the usage of the basic endodontic diagnostic tools by the GDPs in Albaha.
Table 4: Responses of the participants to the diagnostic items

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Working length

The majority of the practitioners (75.43%) are using apex locators for working length determination slightly more than the use of periapical radiographs (71.9%).

Females and younger age group use the tactile sensation more frequently than the others. The difference was significant, P = 0.01 and 0.04, respectively, as shown in [Table 5].
Table 5: Responses of the general dental practitioners regarding working length determinations techniques

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Root canal disinfection

Only very few responses (8.7%) indicate the practice of leaving the tooth open, the majority (80%) of them were practicing in private sector, and all of them have experienced more than 5 years. The majority of the respondents (68.42%) prefer to leave the canals empty between visits.

The majority of the respondents (85.96%) prefer to use sodium hypochlorite for root canal irrigation. However, only 45.61% of them use EDTA for irrigation.

82.45% of the respondents use rotary files for root canal preparation, as shown in [Table 6].
Table 6: Responses of the general dental practitioners regarding root canal disinfection items

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Obturation and follow-up

64.91% of the practitioners take a periapical radiograph for the master cone before they proceed with obturation. Moreover, 84.21% of the participants are taking a postoperative radiograph to assess the obturation. Only 28.07% of the respondents follow up their endodontic cases regularly. [Table 7] illustrates GDPs' responses in relation to obturation and follow-up in endodontic care.
Table 7: Responses of the general dental practitioners to obturation and follow-up items

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  Discussion Top

Several studies have shown a low success rate of the root canal therapy performed by the GDPs compared to endodontically specialized dentists.[11],[12] Moreover, several national and international epidemiological studies have shown a high percentage of poor-quality root canal treatment performed by the general dentist.[13],[14],[15] Therefore, this research aimed to investigate the awareness and attitude of the GDPs toward clinical endodontic practice in Albaha region.

Assessment of the case difficulty is recommended to ensure proper management of the case. To prevent treatment complications, dentists should know their abilities and consider referral depending on endodontic case difficulty assessment.[3] The Ministry of Health of Saudi Arabia clearly identified the endodontic procedures that can be carried out by the GDPs.[5] Yet, the majority of the respondents in this study perform root canal treatment for molars (82.45%), and 94.73% of the private sector practitioners do root canal retreatment for the failing cases. This is partially in agreement with the other national survey in which 73.3% of the GDPs are performing root canal treatment for molars.[8] The reported ignorance of the practitioners toward the case assessment difficulty and referral protocols in this study could be attributed to the awareness level or to financial reasons.

Treatment outcome progression is proportional to the adherence to the regulations and precautions of patient safety protocols.[16] Thereby, the rubber dam application is essential for the safety of the patients and the dentist and to improve the outcome of endodontic treatment.[8] Madarati et al. investigated the preferences and experiences of patients using rubber dam isolation during root canal treatment among the residents of Almadina Almunnawra, Saudi Arabia. They found that the majority of participants would prefer to use it in their next session.[17] The results of the present study showed that only 40.35% of the respondents apply rubber dam routinely for endodontic isolation. It is lower than the findings of Savani et al.,[7] Bogari et al.,[8] and Al-Abdulwahhab et al.[18] and higher than Mathew and Al Nafea[6] and Iqbal et al.[9] Partially, this might explain the low success rate of endodontic treatment in the epidemiological studies.[13],[14],[15]

Pulpal and periapical diagnosis could be a complicated mission sometimes. Therefore, various assessment methods are usually required for proper endodontic diagnosis.[19] The thermal pulp test and EPT have been frequently used for pulpal diagnosis. Unfortunately, in this study, half of the GDPs use the cold test and only 3.5% of them used EPT to confirm the pulpal diagnosis. Similar findings were reported by Bogari et al.[8] Mathew and Al Nafea reported a high percentage of GPDs who never do a pulp test.[6] This will inversely affect the accuracy of the pulpal diagnosis, and treatment might be performed on the wrong tooth.

Furthermore, taking clear preoperative periapical radiographs is essential for case assessment, diagnosis, and follow-up.[9],[14] High percentages of the practitioners (75.43%) in this study take a preoperative periapical radiograph routinely before the procedure. This percentage is in agreement with a study conducted also in Saudi Arabia, where they reported a higher percentage.[5],[8] However, it is in contrast to a similar study conducted in the city of Riyadh, where they reported a (27%) taking preoperative radiographs.[6] Performing root canal treatment without radiographically checking the tooth is below the standard of care. Endodontic guidelines should be followed for better outcome results.[3],[4],[5]

Working length determination is a crucial step in root canal treatment. Although tactile sensation is not accurate method for root canal length determination,[20] about 32% of the practitioners still practicing tactile sensation for working length determination. Interestingly, 61.11% of the practitioners using tactile sensation were female practitioners; the difference between genders was significant (P = 0.005). This finding which is in agreement with Mathew and Al Nafea study in Riyadh city might be attributed to the shortage of the supply and maintenance of the required machines and instruments in some clinics.[6] Eikenberg and Vandre reported that the use of tactile sensation for working length determination gives varied measurements over different patients because of canal patency and curvatures.[21] Electric apex locator is currently considered the best method of determining the working length in vital and necrotic pulp.[22]

An effective irrigation solution combined with the effective application method enhances the root canal treatment outcome.[23] Because of sodium hypochlorite antimicrobial activity, low viscosity, ability to dissolve pulp tissues, lubrication action, and availability, it is considered to be the most frequently used endodontic irrigant.[24] The results of this study reported more practitioners using sodium hypochlorite for root canal irrigation compared to other national studies.[6],[8],[25]

In contrast to the finding of Bogari et al.[8] regarding the usage of intracanal medicaments in particular calcium hydroxide, in which 60.6% of the GDPs reported using of intracanal medicament, only 31.57% of the participants in this study use it. Similar findings were reported by Mathew and Al Nafea[6] and Albahiti.[25] An optimal antibacterial effect of calcium hydroxide was reported when direct contact with microorganisms was achieved.[26] Furthermore, an application of calcium hydroxide for 7 days is sufficient to reduce bacteria in the root canal.[27]

The majority of the respondents (82.45%) in this study used rotary files for root canal preparation, which is higher than Mathew and Al Nafea[6] findings. The introduction of nickel–titanium had revolutionized the endodontic technique. It provides consistent canal shapes, good centering, and faster preparation time.[28] This high use of nickel–titanium instruments among the GDPs might be due to the frequent exposure and availability of hands-on courses.

Despite the importance of the postobturation periapical radiograph, about 16% of the practitioners in this study do not regularly take postobturation radiograph. Furthermore, only 61% of them take a periapical radiograph for the master cone before the obturation. This is much less than Bogari et al. finding.[8] Postobturation radiograph should be taken in order to ensure that the root canal filling was carried out adequately. Patel and Saunders reported that at least one postoperative radiograph is necessary to assess the success of the root canal filling.[29] They consider this radiograph as a baseline for assessment of apical pathology or healing.

A periodic follow-up of the root canal treatment is an integral part of the proper case management to assure successful outcomes.[30],[31] However, only 28.07% of the participants in this study follow up their cases regularly. This finding is similar to the finding of Bogari et al.[8] and in contrast with Jamleh et al. study in which they reported 84% of the respondents routinely perform regular recall with their patients.[31] The difference in results was related to the number of respondents.

The small number of GDPs in Albaha region is the main limitation of this study. Since not all of them participated in this study, the statistical correlation between the different categorical variables might be affected.

  Conclusions Top

A clear deficiency in some aspects of the awareness and clinical practice of the GDPs in Albaha region was observed in this study. Furthermore, several demographic characteristics have shown to influence the endodontic practice. Therefore, it is important to increase the awareness of the GDPs regarding the international and national endodontic practice guidelines.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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