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Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 228-234

Evaluation of undergraduate dental students self-perceived confidence level regarding endodontic procedures: A questionnaire survey

1 Department of Conservative Dental Sciences and Endodontics, College of Dentistry, Qassim University, Buraydah, Saudi Arabia
2 Department of Operative Dentistry, Riphah International University, Islamabad, Pakistan

Date of Submission20-Jun-2020
Date of Decision11-Aug-2020
Date of Acceptance25-Aug-2020
Date of Web Publication8-May-2021

Correspondence Address:
Dr. Muhammad Qasim Javed
Department of Conservative Dental Sciences and Endodontics, College of Dentistry, Qassim University, Buraydah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_155_20

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Introduction: Students' perspectives regarding their educational experiences play an essential role in curriculum planning and to evaluate effectiveness of dental courses being taught. The current study was aimed to assess the undergraduate dental students' self-perceived confidence level while performing different stages of endodontic treatment.
Materials and Methods: A 30-item e-questionnaire was sent to 96 4th and 5th year dental students. The students were requested to grade their self-confidence level regarding various stages of endodontic treatment. Moreover, questions related to endodontics discipline difficulty level and students' preferences of file systems were also asked. Data were statistically analyzed.
Results: The response rate was 94.8%. The students reported the highest confidence level for treating maxillary anterior teeth (4.39 ± 0.94) and the lowest confidence score was noted for maxillary molars (2.75 ± 1.00). Regarding different stages of endodontic treatment, students exhibited the highest confidence level for rubber dam placement (4.43 ± 0.70) while the lowest confidence was documented for managing inter-appointment flare-up (3.45 ± 0.92). A significant association was noted between the level of the academic year and stages of endodontic treatment for the items related to root canal obturation (P = 0.004) and restoration of endodontically treated teeth (P = 0.01). Considering various endodontic indications, 82.4% of the students were confident/very confident while treating the patients with irreversible pulpitis. Contrary to this, the students were least confident while managing the teeth with immature apices (16.5%).
Conclusion: Undergraduate dental students exhibited higher confidence for performing different stages of basic endodontic treatment. Conversely, they reported lower confidence for carrying out more complex procedures.

Keywords: Competency-based education, root canal therapy, self-assessment, survey, undergraduate dental students

How to cite this article:
Javed MQ, Khan AM, Bhatti UA. Evaluation of undergraduate dental students self-perceived confidence level regarding endodontic procedures: A questionnaire survey. Saudi Endod J 2021;11:228-34

How to cite this URL:
Javed MQ, Khan AM, Bhatti UA. Evaluation of undergraduate dental students self-perceived confidence level regarding endodontic procedures: A questionnaire survey. Saudi Endod J [serial online] 2021 [cited 2021 Jun 16];11:228-34. Available from: https://www.saudiendodj.com/text.asp?2021/11/2/228/315640

  Introduction Top

Endodontics is a specialized discipline that focuses on the preservation of normal periapical tissues and restoration of infected/inflamed periapical tissues to the healthy state.[1] Rising endodontic problems and their management constitute a considerable number of clinical cases that need to be promptly dealt with in general dental practice.[2] In the past few decades, the number of individuals seeking endodontic treatment has considerably increased.[3],[4] This could be attributed to an overall rise in life expectancy of the population with an increasing desire to preserve their natural teeth.[1] This increase in endodontic treatment needs requires that the undergraduate dental curriculum should include basic theoretical and clinical skills teaching for the discipline of endodontics. This will enhance both knowledge and skills of future dental clinicians. Subsequently, it will enable them to perform safe endodontic treatment with the provision of quality care to patients by carrying out correct diagnosis, treatment planning, and skillful execution of the endodontic treatment.[5],[6]

Undergraduate Dental Colleges in Saudi Arabia are expected to design and deliver the programs in compliance with the guidelines devised by the Saudi Commission for Health Specialties (SCFHS) while providing teaching and clinical training in endodontics.[7] Also, to acquire necessary skills, students must achieve the competencies that are required to perform endodontic treatment independently after graduation. Considering this, the European Society of Endodontology has provided guidelines for the undergraduate endodontics curriculum. European Society of Endodontology highlighted that the consistency and quality in student's performance, during the preclinical and clinical years are of greater importance than the total number of clinical cases that the students' perform.[8] To evaluate student's proficiency, the most significant parameter is the quality of completed root canal treatments. Also, the periodic evaluation of the students' root canal treatment at the preclinical stage will enhance the quality of patient care in clinics.[9] However, it is generally accepted that the total number of cases done by the students during graduating years also has great impact on general competency as it determines their preparedness to work independently on endodontic cases in future.[10] The recent studies that have evaluated the quality and outcome of endodontic treatments have suggested the high prevalence of poorly executed endodontic procedures performed by students.[11],[12] The possible explanation for this may be the complexity of the root canal system, inadequate understanding of objectives of treatment, and suboptimal clinical skills.[12] It has been reported by Davey et al. that majority of students lack self confidence in performing root canal treatment, mainly due to lack of clinical experience.[13] However, only limited studies are available that have explored the self-confidence level of the students while executing various steps of endodontic therapy. Considering this, the aim of the present study was to assess the undergraduate dental students' self-perceived confidence level while performing different stages of endodontic treatment.

  Materials and Methods Top

The intended sample was undergraduate dental students studying in 4th and 5th years at Qassim University. The approval for the study was obtained from dental ethics committee (ST/6071/2020). The survey questionnaire for the current study was adopted from a previous study.[2] The sample size calculation was carried out by using a calculator by Qualtrics.[14] The total population of students was 96. The confidence level and margin of error were set at 99% and 5%, respectively. The acceptable response rate for the survey was calculated as 87.5%. The questionnaire was sent via an E-mail to the 96 4th and 5th year dental students at the culmination of the academic year. Two E-mail reminders were given at an interval of a week. The students were informed that participation in the study was voluntary. All the students who responded to survey were included in the study and those who did not respond were excluded. The questionnaire had three sections. In the first section, the students were inquired about gender and academic year. The second section was comprised of 30 items; the students' perception regarding their self-confidence level, while performing different stages of endodontic treatment (14 items), managing various endodontic indications (10 items), and carrying out root canal treatment of different teeth type (6 items). The 30 items utilized 5-point of Likert scale as follows: Very confident = 5, Confident = 4, Neutral = 3, Little confidence = 2, 1 = Very little confidence. In the third section, the students' attitude toward patient referral for endodontic treatment in their future practice were assessed. Moreover, the questions related to endodontics discipline difficulty level in comparison with other specialties, students' preference of file systems, and students' satisfaction with the number of endodontic procedures that they were required to perform, were asked. Additionally, students were asked “Do you intend to do postgraduation in Endodontics.” Data analysis was carried out by utilizing SPSS version 23 (IBM Corp, 32 Armonk, NY, USA). Descriptive statistics were recorded as percentages, frequencies, and mean. The association between the dependent and independent variables was determined by using Chi-square test. The level of significance was set at below 0.05 (P < 0.05).

  Results Top

A total of 91 students responded with an overall response rate of 94.8%. The distribution of students, according to their characteristics is shown in [Table 1].
Table 1: Distribution of students according to their characteristics

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In relation to students' perceptions of Endodontic Specialty Difficulty level, 24.2% (n = 22) of the students perceived it as an easy discipline and 64.9% (n = 59) of the students rated endodontics as okay in terms of difficulty. Only 11% (n = 10) of the students considered it as a difficult subject. Moreover, 48.4% (n = 44) of the students showed their interest in pursuing a specialization in the field of endodontics. The majority of students (85%) suggested that in their future practice, they would refer the challenging cases beyond their limit of expertise to a specialist. Furthermore, 62.6% of the students reported they prefer to use both manual and rotary file systems for cleaning and shaping of root canals. However, 20.9% of students showed confidence in using only rotary files, and 16.5% of students were comfortable with manual files while cleaning and shaping canals. Overall, 84.6% of students were satisfied with the number of teeth that they were required to treat during their undergraduate study.

Mean self-perceived confidence scores of students while performing endodontic treatment of different types of teeth are illustrated in [Table 2]. Overall, the mean confidence score was found to be 3.76 ± 0.66. The highest mean confidence score was recorded for maxillary anterior teeth (4.39 ± 0.94). Conversely, the lowest mean confidence score (2.75 ± 1.00) was noted for the Maxillary Molars. The finding was consistent in both academic years. Gender-wise analysis of confidence score of tooth types suggested significant association for the mandibular anterior teeth, where male students (P = 0.01) were found to be more confident than the female counterparts. Similarly, analysis for the association of academic year and teeth type showed a significant difference in scores for Maxillary premolars (P = 0.02), Maxillary molars (P = 0.003), and mandibular molars (P = 0.001). The 5th year students were found to more confident than the 4th year students.
Table 2: Self-perceived confidence level of students while performing endodontic treatment of different types of teeth

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Students' confidence level with regards to different stages of endodontic treatment is described in [Table 3]. Overall mean confidence score was calculated as 4.03 ± 0.50. The self-confidence score was found to be highest for the rubber dam placement (4.43 ± 0.70), whereas, the lowest confidence level was documented for the management of inter-appointment flare-up (3.45 ± 0.92). A significant association was noticed between academic year and stages of endodontic treatment for the items related to root canal obturation (P = 0.004) and restoration of endodontically treated teeth (P = 0.01), where 5th year students were found to be more confident than 4th-year students.
Table 3: Students' self-perceived confidence level with regards to different stages of endodontic treatment

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Student responses to the items regarding their self-confidence levels while managing various endodontic indications are shown in [Table 4]. Notably, 82.4% and 75.8% of the students were confident/very confident while treating the patients with irreversible pulpitis and those requiring endodontic retreatment. Contrary to this, the students were least confident while managing the teeth with immature apices (16.5% confident/very confident) and trauma (24.5% confident/very confident).
Table 4: Self-confidence levels of students while managing various endodontic indications

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  Discussion Top

The dental school of Qassim University is accredited by the National Commission for Academic Accreditation and Assessment and SCFHS.[7] The institution follows the competency-based curriculum. Dental students at Qassim University begin both their practical and didactic endodontic teaching in the 3rd year of their bachelors program. The endodontic requirements for 3rd year include theoretical lectures and 3 h preclinical session weekly. During preclinical sessions students are required to perform the endodontic procedure on 4 single-rooted teeth and 3 multi-rooted teeth (extracted teeth and typhodonts). Also, the students attend the comprehensive workshop on rubber dam isolation that is comprised of the didactic component and hands-on training. Subsequently, in 4th year students, at the beginner level of competency, carry out the endodontic treatment in clinics on 5 teeth (Single rooted with straight canals) and attend hands-on training workshop for rotary instrumentation. Later, in 5th-year students are expected to complete 4 endodontic treatments at intermediate level (2 Single rooted teeth with curved canals and 2 premolars with two canals) and 4 endodontic treatments at competent level (Premolars with curved canals and Molar Teeth). Endodontic treatments are carried out as part of comprehensive patient care under the supervision of specialists.

The evaluation of competence is a vital step for the quality validation of graduating dental students. The competency-based curriculum recognizes essential components for dental practice and provides a sequence of defined learning outcomes that helps students to graduate as a qualified beginner. A recent study suggested that competency-based education may enhance the academic performance and metacognitive capability of students.[15] The improved metacognition of students allows them to perform their self-assessment, which is of significant importance for practical clinical learning.[16] Therefore, it is imperative for students to gain insight into their cognitive processes and develop adequate skills for conducting self-evaluation of their respective competence and confidence levels. The current study is aimed to explore the undergraduate dental students' self-perceived confidence level while performing various stages of endodontic treatment.

The effectiveness of competency-based education in improving the metacognitive ability of the students was evident in the current study, where almost 85% of the students stated that in their future practice they would refer the challenging cases beyond their limit of expertise to a specialist. The finding was comparable to the previous study.[2] Moreover, almost half of the students reported interest in pursuing the specialty of endodontics in future. The result was in line with the outcome of the previous researches.[17],[18] Conversely, other studies documented a lower percentage of students who were interested to specialize in endodontics.[2],[19] The question related to the students' preference of the file systems provided an understanding of their attitudes towards the utilization of contemporary endodontic instruments in the clinical practice. It was encouraging that collectively almost 84% of the students stated that they are confident to use rotary endodontic file systems. The aforementioned confidence was the result of the incorporation of hands-on workshop on rotary Nickle Titanium instrumentation during 4th academic year for improving the quality of endodontic treatment performed by students.[20],[21]

Considering the difficulty of endodontic specialty as compared to other disciplines of clinical dentistry, overall, 11% students (mainly 4th-year students) found the endodontic specialty difficult as compared to the 50% students (mainly 5th-year students) perceiving the endodontics as a difficult specialty in a study by Almohaimede.[19]

The students in the present study reported a lower confidence level while performing the root canal treatment of maxillary and mandibular molar teeth. The findings were consistent with the outcomes reported by Almohaimede, Alrahabi, and Ayhan et al.[19],[22],[23] Nevertheless, 5th year students exhibited significantly higher confidence levels while performing endodontic treatment of molars and maxillary premolars. This might be attributed to the clinical experience and skills gained by the students during their progression from 4th to 5th year, as documented in the research conducted at the University of Bristol.[24] In addition, gender-wise analysis of confidence level with tooth types revealed that male students were significantly more confident in treating mandibular anterior teeth than their female counterparts. A similar gender disparity was noted in the previous studies where male students exhibited higher self-confidence levels while executing complex endodontic procedures.[25],[26] Similar gender differences were also observed in the medical school, where constantly lower confidence in competencies was expressed by female students than their male colleagues.[27]

The overall self confidence level while completing the various stages of endodontic treatment was different for both academic years, with the 5th year students having high confidence level. However, for most of the stages the difference was statistically insignificant. The finding may be attributed to the difference in competencies that the students were expected to achieve by the end of 4th and 5th academic years. As a result, year 4 students perceived themselves confident, and competent to perform endodontic treatment of single-rooted teeth with straight canals. Moreover, it might be secondary to fresh didactic knowledge of year 4 students as most of the theoretical component is covered by the end of year 4. The findings were in line with the results reported by Puryer et al.[24] Likewise, both studies reported a significant difference in the self-confidence level of two cohorts for the restoration of endodontically treated teeth, with 5th year students having a higher confidence level. It was unsurprising that year 4 students reported lower confidence for the restoration of endodontically treated teeth, as this component is not delivered until the students are in the 5th year. However, contrary to Puryer et al.[24] findings in the current study 5th year students reported significantly higher confidence while performing the root canal obturation. Lastly, both academic years reported the highest mean confidence score for the “placement of rubber dam” that was in line with findings of a study conducted in New Zealand.[17] Contrary to this, Tanalp et al. reported a lower mean confidence score of students for rubber dam placement.[2] The higher confidence level in the current study can be attributed to the comprehensive workshop on rubber dam isolation.

The lowest mean confidence score was observed in the current study for the “Management of inter-appointment flare-ups.” Flare-up is described as an acute aggravation of periapical pathology after nonsurgical endodontic treatment is initiated.[28] The flare-ups can occur because of various factors that include apical extrusion of pulpal and dentinal debris, over instrumentation, inadequate pulp tissue removal, irritation from chemicals (medicaments and irrigants), over obturation, microbiologic factors, root fractures, and hyperocclusion.[29] On the other hand, students reported a high confidence level for managing the clinical cases of endodontic retreatment. This can be due to students receiving relatively straight forward retreatment cases carefully selected by their supervisors. The finding was in contrast with the results reported by previous studies where the students reported lower confidence.[2],[23]

Evaluation of the study findings suggested that students reported lower levels of confidence for more intricate endodontics indications that include the treatment of teeth with open apices, root resorption, and endo-perio lesion. The management of the aforementioned cases does not fall in the competencies that undergraduate dental students are expected to achieve.[6] Tanalp et al. documented similar results in their study.[2] They further argued that the students should be exposed to complex endodontic cases. The exposure will enable them to recognize and refer those cases to the endodontist that are beyond their expertise level. Accordingly, Association for Dental Education in Europe stated that Dental student should be competent in identifying the indications for complicated nonsurgical and surgical endodontic treatment and take appropriate action.[6] Thus, the relatively lower confidence level for complex endodontic procedures should not be a matter of concern from the academic perspective. Nevertheless, it should be considered as the depiction of the present limitation of competencies that the undergraduate dental students were expected to achieve.

The standard of clinical teaching that the students receive is expected to reflect in their self-confidence and competency in that particular subject area.[13] However, the students' self-confidence levels (perception of their competency) are not always directly related to their competency.[30] Also, the number of clinical endodontic cases that the students perform does not always reflect their competency level.[25] However, increased exposure to structured clinical experience is likely to improve the students' confidence level and competency.[31] Therefore, it is extremely important that undergraduate dental students should receive adequate clinical exposure to endodontic procedures.[32] Therefore, at Qassim University, students are required to collectively perform endodontic treatment of minimum 20 teeth during preclinical and clinical sessions. The majority of students expressed their satisfaction on the minimum number of root canal treatments that they were required to perform.

The present study had some limitations. First, it is a single centered study, and findings may not be true representative of all dental students across the kingdom. Therefore, multicenter studies should be undertaken to recognize the weak areas in order to bring resolutions for the provision of adequate knowledge and skills during endodontic practices. Second, student's perception of confidence level is highly subjective and individual variations can occur based on their superfluous and impertinent experiences. Despite these limitations, the study can offer a basis for future studies.

  Conclusion Top

The improvement in the perception of self-confidence level was noted with the progression of academic years. However, relative lack of confidence was observed while performing the endodontic treatment of molar teeth, teeth with immature apices and root resorption. Determining the areas of the low confidence level of undergraduate dental students may assist in detailing and incorporation of new teaching methodologies and training approaches in the undergraduate curriculum to enhance the educational experience of the students.


The authors would like to thank all the students of Qassim University College of Dentistry who took part in the study.

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]


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