INTRODUCTION
Dental students' views of their educational practices are a valuable aspect of the development of teaching methods.[1] Several factors can significantly influence learning. Self-assurance, extracurricular activities, clinical practice of theory, and patient–student–teacher connections may be counted among these factors.[2] The aim of dentistry programs is to educate dental professionals based on training and theoretical knowledge. Dental undergraduates enlisted in endodontics should be able to perform at all positions in healthcare, based on scientific and technical expertise.[3]
Besides this, the goal of undergraduate endodontic education is to enable the making of better judgments in all stages of the endodontic treatment process. The stages involve diagnosis, treatment, and follow-up.[4] Many students report that they do not feel adequately prepared to carry out some treatments during their practice. This is especially true of molar root canal therapy, because of the anatomical variety and difficulty of root canals.[5] Furthermore, a sense of personal responsibility for the patients' health is considered an important challenge; though, on the other hand, it can be stimulation for self-development.[6] Valuable feedback and suggestions for revising the educational program can be provided by undergraduate students for the improvement of learning.[4] It is essential to realize how dental students feel about the value of different components during their studies. Hence, feedback is an essential part of the evaluation process, and efficient evaluation can be achieved by the right information, geared toward the success of students and the program.[7] This study aimed to analyze dental undergraduates' perceptions about the difficulties they are facing while performing root canal therapy at a Turkish university, using a survey to identify students' answers to difficulties and to make a dissertation by the educators about possible resolutions.
MATERIALS AND METHODS
This study was approved by the Institutional Review Board of Biruni University (#2018/23-02). All participants signed a consent form. One hundred and six undergraduate students with the same year and level of experience enlisted in endodontics at the College of Dentistry at Biruni University were involved in this survey. The students who have not completed the endodontics clinical course at the tenth semester were excluded from the study. In the seventh, eighth, ninth, and tenth semesters, endodontics clinical courses are provided for the students. Undergraduates perform uncomplicated root canal treatments on anterior teeth and premolars in the seventh and eighth semesters. In the ninth and tenth semesters, undergraduates perform more complicated root canal treatments on molars. Students perform conventional step-back technique and use 2.5% sodium hypochlorite as an irrigation solution in biomechanical preparation. Lateral condensation technique is used in obturation stage, and root canals are filled with AH Plus Root Canal Sealer (Dentsply, DeTrey, Konstanz, Germany) and gutta-percha points. All undergraduate dental students participating in the study had practiced endodontic, preclinical, and clinical procedures during sixth to tenth semester, and answered a survey showed in Tables 1 and 2 based on previous studies by Tavares et al.,[3] with some modification made by at least 5 years experienced assistant professors with regard to the details of processes performed during root canal therapy. In accordance with the root canal treatment stages, answers were divided. Qualitative and quantitative analyses of undergraduates' attitudes to problems at particular phases of root canal therapy were organized by percentage. The data were analyzed using the IBM SPSS Statistics 22 (IBM SPSS, Turkey) program. Chi-square, Fisher-Freeman-Halton tests, and continuity (Yates) correction were used to test for the significance of associations where relevant, with the level of statistical significance set at P < 0.05.
;)
Table 1: Students' responses for the first 13 questions (percentage)
Table 2: Students' responses for 14th, 15th, and 16th questions
RESULTS
The survey was given to 106 undergradutes who had undertaken all endodontic courses during the same semester. About 50.9% of the undergraduates recorded having some difficulty when taking periapical radiographs. About 67% of the undergraduates had trouble identifying root canals. On the other hand, there was a decreasing percentage (58.5%) of those experiencing problems related to radiographic verification of master cone adaptation. The results for “root canal obturation” showed that 54.7% of the dentistry students reported difficulty. Most of the respondents did not report any trouble; especially, in the irrigation process (87.7%) and application of intracanal medication (89.6%) [Table 1].
The answers to 14th, 15th, and 16th question are shown in Table 2.
Moreover, a relation between the 1st, 7th, and 11th parameters was found: participants who had trouble in determining working length also had difficulty in taking a periapical radiograph (55.6%) which is close to significance but not statistically important (P = 0.078). On the other hand, a positive correlation between participants who had trouble in the verification of master cone adaptation and taking periapical radiograph was found (53.7%) (P = 0.016)[Table 3].
Table 3: Correlation between answers regarding difficulty of taking periapical radiograph, working length determination and adaptation of master gutta-percha cone
When the 4th and 6th parameters were examined, a correlation was found between them; participants who claimed to have difficulty in opening endodontic access cavity had also reported having trouble in locating root canals (47.9%) which is statistically significant (P = 0.002). Similarly, considering the 5th and 6th parameters, respondents who had trouble in removing the pulp chamber roof also had difficulty in identifying root canals (56.3%) (P = 0.013).[Table 4]. Furthermore, there was a significant correlation between the 4th and 5th parameters. Students who had problem in opening access cavity also had trouble in removing the pulp chamber roof (79.5%) (P < 0.001)[Table 5].
Table 4: Correlation between answers regarding difficulty of opening access cavity, removing pulp chamber roof, and identification of root canals
Table 5: Correlation between answers regarding difficulty of opening access cavity and removing pulp chamber roof
DISCUSSION
Root canal treatment is a very delicate procedure, depending on the success of many steps. Even a single complication in only one step can cause a negative prognosis.[89] Although the latest developments and techniques used in root canal treatment have been proposed to make the procedure easier, it is still sufficiently complex to be overwhelming for both patient and performer.[10111213] Many dental students have reported feeling stressed and overwhelmed at some point in their education.[4] A large percentage of the dental students find learning endodontics to be complicated, challenging, and stressful because of the various anatomies of teeth and root canals, their responsibility to the patient, and low self-confidence. Because of these issues, many of the students claimed to be incompletely prepared to perform procedures or to make accurate judgments in difficult cases.[5] The aim of this study was to examine the difficulties faced by undergraduate dental students from beginning to end while performing root canal therapy. With this study, the quality of their endodontic education could also be considered. An efficient student–teacher relationship has been reported to be fundamental for good student development.[1415] The learning experience of a dental student has commonly been centered on the teaching crew, whose role is to transfer theoretical and practical knowledge and skills based on their clinical experience. To absorb this knowledge and these skills, dental students must understand why they are learning certain content so that they can make judgments that apply in actual situations.[16] Previous studies also have shown that it is necessary to obtain regular statistics and feedback, as in the present study, to make improvements and correct mistakes, to improve the educational program.[451417181920]
Studies have shown that the most common cause of tooth loss is pulpal or periradicular pathologies. Moreover, root canal therapy is important not only for eliminating these pathologies but also for maintaining teeth in the oral cavity and to support prosthetic restorations if needed.[21] For these reasons, it is fundamental for a dental student to master the difficulties of the procedure and perform high-quality root canal treatment before graduating. To provide these skills, the teaching staff must determine at which step of the procedure the dental student is having trouble. Knowing this leads the educator to focus more on that step to eliminate the cause of the trouble and lead the student to quality root canal therapy.[2]
Regarding the difficulties in taking periapical radiography, our study showed that more than half of the students were having trouble. Similarly, in 2009, Peker and Alkurt stated that the wrong angulation with regard to anatomical areas was one of the most common mistakes among students when taking periapical radiographs.[22] To overcome this problem, the theory must be demonstrated using practical models.[23] In our opinion, using apex locators and specific radiographic film positioners may be helpful once undergraduates approach and apply this knowledge properly.
The present study determined that the greatest problem facing dental students was identifying root canals. Similar findings were reported by Seijo et al.[7] Opening an endodontic access cavity and removing the pulp chamber correctly are very important, to identify the root canals, as shown in this study.[24] Moreover, during the preclinical education process, the quantity of demonstrations with artificial and extracted teeth must be increased by the educators when teaching the performance of clinical procedures. This training is beneficial for dental students, giving them the opportunity to evaluate their experience early.[25]
Another problem was related to root canal obturation. Students in this study find it challenging. Similarly, some studies have indicated that the quality of root canal obturation was far from optimal.[26] In addition, root canal therapy is a lengthy procedure with many steps because of manual preparation and obturation techniques. The procedure takes even longer time with clinically less experienced dental students. Obturation is the last step, and one of the most important steps of the entire procedure, crucial to the prognosis since it establishes apical and coronal seals to prevent microleakage. Taking into account all of these factors, at this last step, both patient and the undergraduate student could be overwhelmed by the stress and the duration of the procedure. To overcome all of these problems, the undergraduate student should be given the opportunity to treat more cases. In addition, the introduction into education schedules of new technologies such as the recently developed mechanical preparation and obturation techniques may develop a student's clinical ability and self-confidence.
On the other hand, the students reported having the least difficulty in irrigation procedures and intracanal medicament application. This may be related to the irrigation procedure requiring less time and effort than other stages of root canal treatment, particularly when compared to mechanical preparation and root canal obturation. Furthermore, applying intracanal medicament is relatively quick, and intracanal medicament is often applied with a rotary instrument rather than manually. As a result of students being confident in irrigation and intracanal medicament application, they seldom appeared in patients' postoperative complaints.
In endodontics, working length determination can be made by radiographic or electrical methods.[27] Both methods are included in the curriculum and taught theoretically to students. However, many of the dental schools in Turkey commonly use the radiographic method instead of apex locators. One of the main reasons for this is the financial cost of apex locators. According to the current study, students who had trouble taking radiographs also had trouble determining working length, since the working length determination technique involves taking periapical radiographs with an initial apical file. Radiographs should not be completely eliminated from the procedure due to their higher accuracy compared with the possibility of false responses from apex locators. Likewise, it is important to improve undergraduates' skills in taking radiograph during their endodontic education. In this regards and in challenging cases, determining working length must be supported with apex locators.[2829] A perfect adaptation of master cone to the apical constriction is an important step for an apical seal to prevents apical microleakage.[30] In the present study, students who had trouble in taking radiographs and determining working length were also found to have trouble with master cone adaptation. This can cause over-filled or under-filled root canal obturations which are shown to have worse prognoses with apical pathology. This problem can likewise be eliminated by improving students' skills.
Successful root canal therapy depends on fully cleaning the root canal space and coronal section of the pulp cavity. This can only be achieved by opening an optimal access cavity to avoid leaving the pulp chamber roof in place, which leads to inadequate cleaning of the pulp chamber and undetermined root canals orifices.[31] In concert with these facts, this study found that undergraduates who had difficulty opening access cavities also had trouble removing the pulp chamber roof, leading to difficulty identifying root canals. Problems opening an access cavity can be logically explained by students working on extracted human teeth with no caries cavities to enable them to study the optimal borders of the specific access cavity of each tooth. On the other hand, students face various types of tooth anatomy and caries cavities with different borders when dealing with a patient's teeth. In this situation, it is reasonable to attribute undergraduates' difficulties in eliminating caries while providing an optimal access cavity to their lack of clinical experience and fear of causing perforation.[32] Hence, it is understandable for undergraduates to lack confidence due to their inadequate experience. To solve this problem, extracted teeth with an acceptable amount of caries cavities could be used in the student's preclinic session. Furthermore, in endodontics clinics, diagnostic radiograph must not only be used to examine root canals and the periapical area but also the crown of the tooth, to determine the extent of caries and the borders of the pulp chamber. Bitewing radiographs can also be included to support the examination so that students can feel safer when opening the access cavity and removing the pulp chamber roof.
Irrigation procedure is one of the essential steps of root canal treatment.[33] In the present study, more than half of the students who experienced problems with root canal therapy also had problems with the irrigation procedure. Furthermore, irrigation accidents can often be experienced in endodontic therapy. In this manner, a serious ratio of complications occurs during the irrigation stage, as we demonstrated in this study. Lectures about endodontic mishaps such as extrusion of irrigation solution are given in our endodontic courses. Further lectures about irrigation complications should be given prominence by educators, and type of endodontic irrigation needles used in undergraduates' clinics to avoid this situation. Beyond this, active learning methodologies appear more beneficial to undergraduate students.[3]
Postoperative patients' complaints might be expected after a complication in endodontic treatment. Similarly, in the present study, there is evidence that postoperative complaints are related to complications during root canal treatment. To overcome this, the number of endodontic teaching staff could be increased to give more attention to the students in clinics. Moreover, regular feedback received from undergraduates is very important and should be used to address the points of concern that they raise.
CONCLUSION
Determining the major difficulties of undergraduate students during endodontic treatment may help detailing teaching strategies during the endodontics education process. According to the present study, points that need to be given greater prominence during the education process are periapical radiographs, identification of root canals, and root canal obturation. Although further studies should be required about this subject, this survey study helped to discover various gaps in the education schedule which, if altered correctly, would be of great benefit to both the quality of undergraduates' performance and the time dentistry schools spend trying to deal with these issues.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Oliver R, Kersten H, Vinkka-Puhakka H, Alpasan G, Bearn D, Cema I, et al Curriculum structure: Principles and strategy Eur J Dent Educ. 2008;12(Suppl 1):74–84
2. Lanning SK, Wetzel AP, Baines MB, Ellen Byrne B. Evaluation of a revised curriculum: A four-year qualitative study of student perceptions J Dent Educ. 2012;76:1323–33
3. Tavares LG, Lima SM, Lima MG, Arruda MP, Menegazzi TC, Rezende TM. Undergraduate dentistry students' perception of difficulties regarding endodontic treatment Aust Endod J. 2019;45:98–105
4. Henzi D, Davis E, Jasinevicius R, Hendricson W, Cintron L, Isaacs M. Appraisal of the dental school learning environment: The students' view J Dent Educ. 2005;69:1137–47
5. Rolland S, Hobson R, Hanwell S. Clinical competency exercises: Some student perceptions Eur J Dent Educ. 2007;11:184–91
6. Divaris K, Barlow PJ, Chendea SA, Cheong WS, Dounis A, Dragan IF, et al The academic environment: The students' perspective Eur J Dent Educ. 2008;12(Suppl 1):120–30
7. Seijo MO, Ferreira EF, Ribeiro Sobrinho AP, Paiva SM, Martins RC. Learning experience in endodontics: Brazilian students' perceptions J Dent Educ. 2013;77:648–55
8. Barrieshi-Nusair KM, Al-Omari MA, Al-Hiyasat AS. Radiographic technical quality of root canal treatment performed by dental students at the dental teaching center in Jordan J Dent. 2004;32:301–7
9. Er O, Sagsen B, Maden M, Cinar S, Kahraman Y. Radiographic technical quality of root fillings performed by dental students in Turkey Int Endod J. 2006;39:867–72
10. Kuzekanani M. Nickel-titanium rotary instruments: Development of the single-file systems J Int Soc Prev Community Dent. 2018;8:386–90
11. Gluskin AH, Brown DC, Buchanan LS. A reconstructed computerized tomographic comparison of ni-ti rotary GT files versus traditional instruments in canals shaped by novice operators Int Endod J. 2001;34:476–84
12. Baumann MA. Nickel-titanium: Options and challenges Dent Clin North Am. 2004;48:55–67
13. Peru M, Peru C, Mannocci F, Sherriff M, Buchanan LS, Pitt Ford TR. Hand and nickel-titanium root canal instrumentation performed by dental students: A micro-computed tomographic study Eur J Dent Educ. 2006;10:52–9
14. Gerzina TM, McLean T, Fairley J. Dental clinical teaching: Perceptions of students and teachers J Dent Educ. 2005;69:1377–84
15. Connor JP, Troendle K. Perspectives on the dental school learning environment: Putting theory X and theory Y into action in dental education J Dent Educ. 2008;72:1436–9
16. Alam M. Banking model of education in teacher-centered class: A critical assessment Res Hum Soc Sci. 2013;3:27–31
17. Cardall WR, Rowan RC, Bay C. Dental education from the students' perspective: Curriculum and climate J Dent Educ. 2008;72:600–9
18. Henzi D, Davis E, Jasinevicius R, Hendricson W. North American dental students' perspectives about their clinical education J Dent Educ. 2006;70:361–77
19. Henzi D, Davis E, Jasinevicius R, Hendricson W. In the students' own words: What are the strengths and weaknesses of the dental school curriculum? J Dent Educ. 2007;71:632–45
20. Bush H, Bissell V. The evaluation of an approach to reflective learning in the undergraduate dental curriculum Eur J Dent Educ. 2008;12:103–10
21. Ingle JI, Baumgartner JC. Ingle's Endodontics 2008;6 Philadelphia PMPH:16–21
22. Peker I, Alkurt MT. Evaluation of radiographic errors made by undergraduate dental students in periapical radiography N Y State Dent J. 2009;75:45–8
23. Chandrasekaran B, Cugati N, Kumaresan R. Dental students' perception and anxiety levels during their first local anesthetic injection Malays J Med Sci. 2014;21:45–51
24. Rampado ME, Tjäderhane L, Friedman S, Hamstra SJ. The benefit of the operating microscope for access cavity preparation by undergraduate students J Endod. 2004;30:863–7
25. Nassri MR, Carlik J, da Silva CR, Okagawa RE, Lin S. Critical analysis of artificial teeth for endodontic teaching J Appl Oral Sci. 2008;16:43–9
26. Moradi S, Gharechahi M. Quality of root canal obturation performed by senior undergraduate dental students Iran Endod J. 2014;9:66–70
27. Sharma MC, Arora V. Determination of working length of root canal Med J Armed Forces India. 2010;66:231–4
28. Mello I. Use of electronic apex locators may improve determination of working length Evid Based Dent. 2014;15:120.
29. Tinaz AC, Maden M, Aydin C, Türköz E. The accuracy of three different electronic root canal measuring devices: An in vitro evaluation J Oral Sci. 2002;44:91–5
30. Jamleh A, Awawdeh L, Albanyan H, Masuadi E, Alfouzan K. Apical gutta-percha cone adaptation and degree of tug-back sensation after canal preparation Saudi Endod J. 2016;6:131–5
31. Deutsch AS, Musikant BL. Morphological measurements of anatomic landmarks in human maxillary and mandibular molar pulp chambers J Endod. 2004;30:388–90
32. Cohen S, Burns R. Cohen's Pathways of the Pulp Expert Consult 201611th St. Louis, MO, USA Mosby
33. Mohammadi Z, Jafarzadeh H, Shalavi S, Kinoshita JI. Unusual root canal irrigation solutions J Contemp Dent Pract. 2017;18:415–20
