The main goals of endodontic treatment are saving natural teeth and restoring the health of periapical tissues which have biological, functional, esthetic, and financial advantages. Endodontic treatment outcomes are affected by multiple prognostic factors that should always be discussed with patients. Some of those important factors include pulpal and periapical status, the level of canals debridement and obturation quality, procedure errors, the quality of coronal restoration, and the introduction of innovative instruments used by the dentists according to his/her skills and knowledge. In addition, several studies suggested a negative influence between systemic diseases and root canal treatment (RCT) outcomes such as diabetes, hypertension, and coronary artery diseases. Moreover, dentists can play an important role in detecting life-threatening conditions (e.g., hypertension) by routinely measuring blood pressure (BP). However, the importance of this seems to be underappreciated in the dental field. Large number of RCTs are provided by general dental practitioners (GDPs) worldwide; however, studies have shown that most GDPs disregard basic principles of endodontic therapy, and so, the success rate of endodontic treatment performed by GDPs is low and below expectations. This discrepancy in the success rate might reflect a difference in the technical quality of the endodontic treatment performed. Several studies have investigated the knowledge and attitudes of dentists toward RCT procedures. This includes studies performed in the United States, the United Kingdom (UK), Germany, Iran, India, and Pakistan. However, few studies had been conducted in Saudi Arabia. All of the studies cited here have reported that the majority of GDPs do not follow the guidelines for standard RCT. Therefore, here, we aimed to assess the knowledge and attitude of GDPs toward performing the proper standards of care while managing patients undergoing endodontic treatment in Saudi Arabia.
MATERIALS AND METHODS
An anonymous English-language e-questionnaire was formulated using Google Forms. The e-questionnaire was distributed among GDPs in Saudi Arabia (n = 650). This study targeted GDPs working in major cities all around Saudi Arabia such as Jeddah, Mecca, Al-Taif, Al-Madina, Riyadh, Al-Damman, Al-Qassim, and Tabuk. The e-questionnaire stem contained the title and the purpose of conducting the project. All participants confirmed that they answered the questions to the best of their knowledge and according to their daily dental management in practice. Furthermore, participants agreed to the use of the provided information for research and educational purposes. The final version of the e-questionnaire was reached after distributing 35 questionnaires to assess the clarity and validity of the questions, which resulted in a few modifications. The e-questionnaire was composed of 32 questions that assessed the knowledge, attitude, and performance of GDPs toward practicing the proper standards of endodontic treatment in their clinic. The e-questionnaire was sent randomly by text message to all 650 GDPs practicing in different cities in Saudi Arabia at the same time, and then a reminder was sent 3 weeks after to the ones that did not respond.
The e-questionnaire included written consent, which was provided by all participants. The e-questionnaire was approved by the Research Ethics Committee Review Board from King Abdulaziz University, Faculty of Dentistry, Ref. number 014-01-17. This project was approved by the committee and was in full accordance with the World Medical Association Declaration of Helsinki.
IBM SPSS Version 22, (Armonk, New York, USA). Simple descriptive statistics were used to define the characteristics of the study variables using numbers and percentages for categorical variables. To establish a relation between categorical variables, we used the Chi-square test, where a P < 0.05 was taken to indicate statistical significance. All of the significant variables are listed in the tabulated representations.
The response rate was 50.03%. Among the total respondents, 64.8% were male and 35.2% were female. Most of our participants were newly graduates (54.1%) and working in private practice (54.0%). The demographic data of the respondents are given in [Table 1].
Most of the participants reported obtaining medical history before RCT (82.3%). However, only 12.2% of the GDPs always measure the BP for their patients before starting RCT, and 80.1% of the GDPs screen their patients for problems other than the chief complaint and tell them about these findings [Figure 1].
There were significant differences between males and females (P < 0.05) and between people who worked in a government hospital versus private practice and hospital jobs (P < 0.05) in regard to screening for problems other than the chief complaint. In addition, comparing genders, there was a significant difference in medical history taking (P < 0.05) [Table 2].
Infection control and rubber dam application
Among the participated dentists, 75.5% wash their hands before and after treating each patient, and the majority of the respondents, i.e. 80.7%, change the hand-piece between patients as part of their dental practice policy [Figure 2a and b]. The latter was significant (P < 0.05) among practitioners working in different sectors [Table 2]. About 65% of the participating dentists believe that disinfecting the hand-piece after each patient is not sufficient after performing endodontic treatment [Figure 2c]. This was significant (P < 0.05) between males and females [Table 2].
Regarding rubber dam application, 56.3% of the participating dentists are applying rubber dam isolation when performing RCT, while 24.2% believe that partial isolation is sufficient for this procedure [Figure 2d]. Unfortunately, 19.6% of the dentists perform RCT without rubber dam isolation [Figure 2d]. This was statistically significant in terms of gender (P < 0.05), duration since graduation (P < 0.05), and working area (P < 0.05) [Table 2].
Endodontic diagnosis and radiographic assessment
Regarding diagnosis of teeth that need RCT, 42.8% of the participating dentists use a cold test to confirm their decision, 55.5% think that percussion is a reliable method for diagnosis, and 21.4% use a perio-probe to check the presence of any pocket depth around the affected tooth before starting the RCT procedure [Figure 3a,Figure 3b,Figure 3c]. Regarding the use of the cold test to confirm the endodontic diagnosis, we detected significant differences in terms of genders (P < 0.05), the time since graduation (P < 0.05), and working sector (P < 0.05) [Table 2].
Approximately 86.9% and 89.9% of the GDPs take preoperative radiographs and postoperative periapical radiographs before and after RCT, respectively [Figure 3d and e]. The majority (70.3%) of the GDPs might take one or more radiographs depending on the case, while 19.3% rely on only one straight-angled radiograph [Figure 3f]. There was a significant difference in taking posttreatment periapical radiograph and the time elapsed since graduation (P < 0.05) and working sector (P < 0.05) [Table 2].
Irrigation solutions used in root canal treatment
Sodium hypochlorite (NaOCl) irrigation solution is used by 44.6% (full concentration) and 50.8% (diluted) of the participants. In addition, 56.6% mentioned using saline as irrigation solution compared to 30.6% who mentioned using ethylenediaminetetraacetic acid [Table 3].
Working length determination, intracanal medication, and temporary restoration
Regarding working length (WL) determination, 33.1% of the respondents are using conventional radiographs, whereas 14.4% reported using electronic apex locators (EALs) and 52.1% are using a combination of both radiography and EAL [Figure 4a]. Most practitioners (60.6%) use intracanal medication (ICM) between RCT visits [Figure 4b]. Cavit is the most preferred temporary filling material (51.1%), followed by glass ionomer (32.1%) and IRM (14.7%) [Figure 4c].
Performing root canal treatment on the posterior teeth and challenging retreatment cases
About 73.3% of the GDPs reported that they perform RCT procedures on molars. However, 55.4% perform only simple retreatment cases and refer the difficult ones [Figure 5a and b].
Number of visits
About 52.6% of the GDPs complete RCTs in two visits, while 30.9% do it in more than two visits. Only 16.5% reported completing RCT in single visits [Figure 5c].
Painkiller and antibiotic usage
About 77.7% of the practitioners instruct their patients to take painkillers after RCT only if they feel pain [Figure 5d]. Ibuprofen (400 mg) is the most commonly prescribed painkiller (49.8%), followed by ibuprofen (600 mg, 26%) and then acetaminophen (16.2%) [Figure 5e]. In addition, 19.3% of the dentists believe that prescribing an antibiotic after RCT will decrease postoperative pain [Figure 5f].
Managing cases of pulpitis, necrosis, abscess, and badly decayed teeth
About 48.3% of the GDPs never prescribed antibiotics in cases of severe pain and confirmed the diagnosis of irreversible pulpitis, while 51.7% might prescribe antibiotics at different occasions, such as a couple of days before or after starting RCT [Figure 6a]. In case of patients who were diagnosed with pulp necrosis (nonvital tooth) and had localized fluctuating swelling, 34.9% of the participating dentists mentioned prescribing antibiotics for a couple of days then starting RCT, whereas 34.6% mentioned starting RCT, performing incision and drainage, and then prescribing antibiotics [Figure 6b]. However, 19.6% of the participating dentists will start RCT and perform incision and drainage without the need for prescribing antibiotics [Figure 6b]. In abscess cases, 47.1% of the dentists would never leave the tooth open for pain relief and drainage, while 37.3% sometimes do so [Figure 6c]. In case of badly decayed but still restorable teeth, the majority of GDPs will suggest the treatment plan of undergoing RCT and then crowing the tooth (85.6%), while only 10.1% suggest extraction and undergoing implant replacement [Figure 6d].
In the present study, only 28.7% of the participants mentioned performing regular follow-up for their cases after RCT, whereas 55.0% would do so occasionally [Figure 6e]. About 35.3% believe that the follow-up of 6 months is sufficient compared to 25.2% and 12.6% who suggest a 1-year follow-up or more, respectively [Figure 6f].
This study was conducted to assess the knowledge and attitude of GDPs toward performing the proper standards of care while managing patients undergoing endodontic treatment in Saudi Arabia. This study targeted GDPs because epidemiological studies have shown that the failure rate of RCTs is higher among teeth treated by nonspecialized dentists compared to endodontists. We believe that GDPs should always follow endodontic standard guidelines recommended by well-known endodontic societies such as the American Association of Endodontists (AAE). The Saudi Council of Endodontics is following the AAE guidelines, especially for diagnosis and other important clinical aspects in endodontics. In addition, te AAE guidelines for diagnosis is the official dental terms of the educational centers in Saudi Arabia. Our survey questions evaluated key steps that must be taken in the process of performing RCT. Violation of the proper standards in these steps by GDPs can affect the treatment outcome. Although the majority of our participants mentioned taking the full medical history of patients before RCT, 17.7% do not, which can be considered a clear violation of the proper standard of care. Accurate and complete recording of a patient's medical history can help the dentists to achieve an accurate diagnosis, assist treatment modification and planning, prevent unexpected complications during and after treatment, and also ensure better prognosis and treatment outcome. Moreover, only 12.2% measure the BP routinely of all patients. This result is in agreement with Greenwood and Lowry, who reported that 4.8% of GDPs measure routinely the BP, and this percentage reached to 9.2% when patients mentioned a BP issue. Hypertension is one of the leading causes of death worldwide and is a major risk factor for heart disease and stroke. Thus, increasing GDPs awareness about hypertension and emphasizing their role in screening patients for such disease will surely help in early detection and diagnosis and aid in better management and treatment of these patients.
Patient safety regulations are essential and aim to improve the quality of patient care, decrease treatment mistakes, and progress treatment outcomes. Thus, infection control safety procedures focus on preventing or limiting factors, contributing to the transmission or spreading of infection in dental clinics. The AAE applies standard of care procedures and precautions to reduce the risk of infection transmission in dental clinics, such as wearing protective equipment, maintaining hand hygiene, and changing and sterilizing instruments after every patient. Rubber dam isolation is another important precaution that might help protect patients and dentists and improve the quality and success of RCT. Our results show that the majority of the GDPs wash their hands properly before and after treating each patient and do change the hand-piece routinely after every patient. However, unfortunately, only 56.3% apply rubber dam isolation in all cases and 24.2% still believe that partial isolation is sufficient in RCTs. The percentage of 56.3% in this study is higher than previous studies in Saudi Arabia, which have reported rates of 9%–14.7%, and other parts of the world, including the UK (19%), Turkey (5.1%), Burkina Faso (6.1%), and India (3.2%). Nevertheless, this major issue defeats the main biological goal of performing RCTs, which is decreasing bacterial load in the canals to ensure more promising treatment outcomes and resolution of periapical infections. Studies suggest some factors to expand the use of the rubber dam, such as enhancing the concept of using it in undergraduate and postgraduate training, enhancing patient's education, and applying strict governmental laws for its use.
Pulpal diagnosis can be a challenging task for GDPs. It is well known that the applied tests have greater specificity than sensitivity. Thus, several tests are always required to reach a proper definite endodontic diagnosis. Dental pulp tests, such as cold test and the electronic pulp test (EPT), have been commonly used and are helpful aids to endodontic diagnosis. In addition, it was found that using cold pulp test in combination with an EPT, for the evaluation of pulp vitality, provided more accurate results than using one of them alone. Here, 42.8% of the GDPs use the cold test to confirm their diagnosis of teeth that needed RCT, while 55.5% thought that percussion is a reliable method for endodontic diagnosis, and only 21.4% use a perio-probe to check for the presence of pocket depth around the affected tooth before starting the procedure. This, unfortunately, shows a lack of knowledge of our GDPs in regard to endodontic diagnosis protocols. Positive percussion test results can only indicate an inflammation at the periapical area, but it is not always necessary to be of endodontic origin. Thus, percussion tests tend to have low specificity and sensitivity values compared to the cold test, especially when it comes to the diagnosis of cases with irreversible pulpitis. The pain of periodontal origin can sometimes mimic pulpal pain symptoms. Thus, to prevent misdiagnosis, perio-probing should not be neglected.
Taking good preoperative radiographs at multiple angles can play a significant role in the diagnosis and treatment planning process. Such radiographs would provide dentists with useful information, such as the presence, extent, and severity of periapical pathology. Furthermore, taking postoperative radiographs is important from a medico-legal point of view and provides baseline information for follow-up and assessment of treatment outcome. Indeed, the majority (86.9%) of the participants take preoperative radiographs before RCT procedures. This percentage is in agreement with a study conducted in Karachi, but in contrast to a similar study conducted in the city of Riyadh, Saudi Arabia, where they reported a much lower percentage (27%). This may be explained, at least in part, that our study included GDPs from major cities around Saudi Arabia compared to all other published studies that conducted their study only in one city or single region of Saudi. On the other hand, our results also revealed that a high percentage of our GDPs (89.9%) do take postoperative radiographs after treatment, which is similarly reported by a study conducted among UK dentists (75%).
Determination of the WL is a critical step in endodontic treatment. Inaccurate determination of the WL might lead to several complications, including over-instrumentation, over-extension of the irrigation solution, obturation of materials into the periapical tissues, incomplete instrumentation, bacterial retention, and defective obturation, all of which can affect the long-term treatment outcome. Radiography, EAL, and tactile sensation are methods that have been used for WL determination. Although it remains controversial whether the use of EAL is more accurate in determining the WL than traditional methods such as radiograph and tactile sensation, it is believed that EAL decreases unnecessary patients' repeated exposure to radiographic radiation until achieving the appreciated WL and preventing over-instrumentation and violation of the apical construction. In our study, 52.1% of the GDPs prefer using both EAL and radiographs to determine the desired WL, compared to 33.4% who still prefer using the radiographs. Other studies have also reported that GDPs prefer radiographic WL determination methods.
Understanding the chemo-mechanical principles of root canal debridement represents the core element of successful endodontic treatment. Thus, selection of proper irrigation solution and concentration, combined with the proper method of application, can affect the disruption of biofilm in the canals and reduce the bacterial load, thus contributing to better treatment outcome. The most frequently adopted irrigation solution is NaOCl because it can dissolve organic tissue, and it has broad antimicrobial spectrum properties compared to other solutions. Our results show that about half of the GDPs use NaOCl either in full or diluted concentration. Studies show that only NaOCl at high concentration (~5.25%) can disrupt biofilms and effectively kill most of the bacteria. In addition, high percentage of GDPs mentioned using saline as an irrigant in endodontics. They need to keep in mind that saline can be used as an adjunct solution to NaOCl or others depending on the case; however, it should not be considered the sole irrigant due to its ineffectiveness as antimicrobial agent. This issue seems to be a common mistake among GDPs worldwide. However, others have reported that NaOCI, regardless of the concentration, remains the most commonly used irrigation solution in their countries.
In regard to ICM between RCT visits, 60.6% of our participants report using ICM. ICM, such as calcium hydroxide, plays an important role in decreasing bacterial load when used between RCT visits. Further, ICM indirectly aids in the healing process of the affected periapical tissues and forming an additional coronal seal for temporary restorations. Our study is in agreement with others that have reported the use of ICM (mostly calcium hydroxide) between visits.
To date, there is no single temporary or interim ideal restoration to be used with teeth undergoing RCT. Thus, GDPs should use their judgment to select the suitable temporary restoration that can be easily distinguished from natural tooth structure for easy removal between appointment, and also has considerable tensile strength to achieve good coronal seal. In the current study, cavit was the preferred temporary filling used to seal the coronal access after RCT (51.1%), followed by glass ionomer (32.1%) and IRM (14.7%). Similar results were reported by others where cavit was still the preferred temporary filling used by GDPs (77.7%).
In regard to GDP's endodontic case selection and management, we found that 73.3% of the GDPs do perform RCT on molars and that 55.4% perform simple retreatment cases and refer others. In addition, only 16.5% of the GDPs complete RCTs in one visit, compared to 52.6% and 30.9% that would finish the RCTs in two or more visits, respectively. This is in agreement with other studies where GDPs also need two or more visits to complete RCTs. To prevent any undesired treatment outcomes and complications, GDPs should be aware of their limits and capabilities and consider referral depending on endodontic case difficulty assessment. Burry et al. reported that, after 10 years, molars treated by endodontists have significantly higher survival rates than molars treated by nonendodontists. This finding demonstrates the importance of GDPs understanding their limitations when attempting to perform RCTs.
Pain management in dentistry can be challenging. In the current study, 77.7% of the practitioners instruct their patients to take painkillers after RCT only if they feel pain, while only 20.2% prescribe painkillers routinely. Among our practitioners, ibuprofen (400 mg, 49.8%) was the most common painkiller prescribed, followed by ibuprofen (600 mg, 26%) and then acetaminophen (panadol or solpadeine) (16.2%). Postoperative pain after RCT is expected and can be managed with the prescription of postoperative painkillers, where ibuprofen (600 mg) seems to be an acceptable dose for mild-to-moderate cases, due to its analgesic and anti-inflammatory effect, with a good number needed to treat compared to acetaminophen, codeine, and diclofenac (voltaren).
Adjunctive antibiotic prescription guidelines have been recommended by the AAE-Endodontics. The prescription of antibiotics includes cases such as the presence of trismus, increased swelling, and cellulitis. However, the presence of pain or cases of irreversible pulpitis or necrotic teeth do not require the prescription of antibiotics. In our study, 48.3% of the participants believe that prescribing antibiotics after RCT would do nothing to decrease postoperative pain; however, in case of necrotic teeth with swelling, 34.9% prefer prescribing antibiotics for a couple of days before starting treatment. To prevent the increase of drug-resistant microbes, GDPs should be careful when it comes to prescribing antibiotics and should adhere to the recommended guidelines. Our data also show that 52.9% of the participants still consider leaving the tooth open in cases of tooth abscess. This misconcept must be taken seriously as it undermines the whole concept of canal debridement and elimination of the source of infection to decrease the cause of the pain and swelling.
Regarding restoring badly decayed teeth, the majority of the GDPs recommend performing RCT 85.6%, while 11% suggested to extract the teeth and to provide implants. The AAE-position statement states that placing an implant where a tooth can still be restored is considered unethical; thus, caution should always be taken by both GDPs and endodontists when it comes to discussing treatment planning for compromised teeth. It is always advisable to discuss such treatments as a team and also consider the patient autonomy.
Finally, it is important to understand that RCT does not end with the obturation step. Achieving final coverage and following up of the case to ensure that healing has taken place should be an integral part of RCT. Here, we found that only 28.7% of the participants follow up their cases and 35.3% of them believe that 6 months is a good follow-up period. The favorable outcome of endodontic treatment depends on the absence of signs and symptoms and the decrease/resolution of periapical lesions. Therefore, the delayed disappearance of the apical lesion should not be considered as a failure as long as the involved teeth are functional and in the healing phase. In addition, radiographic follow-up of periapical status after endodontic treatment can be noticeable from 3 months to 2 years depending on the size of the periapical lesion, where 1 year seems to be a good follow-up point for treatment evaluation.
To improve the quality of treatment and to ensure that Saudi patients achieve promising and predictable treatment outcomes, there is an urgent need to increase the knowledge and awareness of the GDPs toward following endodontic standard guidelines recommended by well-known endodontic societies (e.g. AAE). Following these standards should always be emphasized when developing dental curriculum and highlighted in continuing dental education courses. We hope that publishing this study will highlight where lack of knowledge and poor attitude exist while performing RCT by GDPs in Saudi and thus help in raising treatment standards.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
We acknowledge and thank Kalvin Balucanag and his team for helping with the data tabulation and analysis. We also thank Dr. Majdi Munshi and Dr. Omer F. Alqurashi for their help in distributing the e-questionnaire.
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