Quality of root canal treatment performed by undergraduate dental students in Saveetha Dental College and Hospitals

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1 Research Article Quality of root canal treatment performed by undergraduate dental students in Saveetha Dental College and Hospitals Kayalvili Sanmugam, James David Raj* ABSTRACT Aim: The aim of the study was to evaluate the quality of root canal treatment (RCT) performed by undergraduate (UG) dental students in Saveetha Dental College and Hospitals using radiographic records. Objective: The objective of the study was to assess the radiographic technical quality of root canal fillings done by UG dental students in Saveetha Dental College based on the length of the, density, and taper. Methods: A total of 107 post-operative radiographs of RCT done by the UG students were collected. The quality of the filling based on the length of the, density, and taper was assessed. Scores of 0, 1, and 2 were given by 2 experienced endodontists. Data collected were documented, and statistical analysis was done. Results: Perfectly length of the root filling was found in 36.27% of teeth, while 44% were length and 18.90% were un. Perfectly density was found in 16.77% of teeth, density was found in 60.41% of teeth, and un was found in 22.86% of teeth. Regarding the taper of the root canal filling, 19.30% were perfectly, 68.37% were, and 19.06% were un. The frequency of root canal with was significantly higher than the. Conclusion: The technical quality of root canal filling performed by UG dental students was mostly. However, to improve the quality of treatment performed by these students, the course of endodontic has to be improved at both preclinical and clinical levels. KEY WORDS: Radiograph, Root canal filling, Root canal treatment, Technical quality, Undergraduate dental students INTRODUCTION Root canal treatment which is also known as endodontic treatment is a treatment done for the infected pulp of a tooth which results in the complete removal of infection and protect the tooth from future microbial invasion. [1] Root canals, and their associated pulp chamber, are the physical hollows within a tooth that is naturally inhabited by nerve tissue, blood vessels, and other cellular entities. [2] Endodontic therapy involves the removal of dental pulp. Then, it is followed by subsequent cleaning and shaping and then decontamination of the hollows with small files and irrigating solutions and finally, (filling) of the decontaminated canals. Filling of the cleaned and decontaminated canals is done with an inert filling Access this article online Website: jprsolutions.info ISSN: such as gutta-percha and typically a eugenol-based cement. [3] Endodontic treatment is needed when the pulp and the soft tissue inside the root canal become inflamed or infected. The inflammation or infection can have a variety of causes: Deep decay repeated dental procedures on the tooth, or a crack or chip in the tooth. Bacteria break down when the dental pulp is damaged. The bacteria then begin to multiply within the pulp chamber. The bacteria and other decayed debris can cause an infection or abscessed tooth. An abscess is a pus-filled pocket that forms at the end of the roots of the tooth. It occurs when the infection spreads all the way past the ends of the roots of the tooth. Because pulp is removed from the canal during root canal treatment (RCT), the teeth involved can no longer function as living things. Over time, this deficit causes them to lose strength and become likely to fracture. This is why a crown is needed after RCT. Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India *Corresponding author: Dr. James David Raj, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, 162, Poonamallee High Road, Chennai , Tamil Nadu, India. Phone: jamesdraj@gmail.com Received on: ; Revised on: ; Accepted on:

2 A cap is a tooth-shaped crown that is placed over a tooth to restore its shape and size, strength, and also to improve the appearance. The crowns which are cemented into place cover the full portion of a tooth that lies at and above the gum line. On average, dental crowns past 5 15 years. The amount of wear and tear, oral hygiene practices and mouth related habits determine the lifespan of a crown. Permanent fillings are done to strengthen the teeth and protect the treated teeth after a RCT. For many root canal procedures, however, fitting crowns over the filled teeth is necessary. This is due to the high risk of fracture without the extra protection crowns provide. Crowns help to restore the natural appearance of your teeth. Root canal filling is an important step in endodontic treatment. The quality of RCT has significant influence on endodontic therapy outcomes. The technical quality of root fillings is determined by its length of, density, and taper. Recent years have seen a marked increase in the demand of patients for RCT due to the increased age of the population, so dental students should possess the knowledge and skills in this discipline before the need increases even more. [4] The assessment of dental student performance in endodontics will help to improve dental education. Therefore, UG training should promote the comprehension of RCT outcome and related factors. [5] The majority of RCTs are performed by general practitioners in everyday clinical practice. It is very important that students achieve a certain level of competence over their course of education through preclinical and clinical courses. The learning process should be continued throughout the entire work span of a dentist. [6] Epidemiological studies showed that the technical quality of RCT performed by general practitioners is at a low level (20.840%). [7-9] The reasons are complex and may be related to the different endodontic teaching methods at dental school. [10] Some of the problems in endodontic teaching may be attributed to limited time allocated to endodontics, poor staff-to-student ratios and the fact that many endodontists have not taken the teaching skills. It has been reported that one of the causes of such poor quality treatment in general practice may be that students graduate with a lack of expertise and a poor understanding of the principals involved. [11] RCT deals with maintenance and preservation of periapical health through chemomechanical debridement. The three dimensional of root canal space prevents intraradicular microorganism and their toxins from reaching the periapical tissue. [12,13] RCT success can be evaluated by radiographic or clinical findings alone or both. [14] Radiographic evaluation represents a very frequent method of assessment. [15] Several authors [8,9,16,17] reported the occurrence of apical periodontitis in teeth with adequate root fillings. Hence, this important variable should be taken into consideration when evaluating RCT success. The aim of RCT is to prevent apical periodontitis or to create optimal conditions for healing of the periapical tissues. Elimination of the bacteria and removal of infection from the root canal system will help avoid reinfection. [18] Students are taught endodontics from 3 rd year onward until internship, at Saveetha Dental College and Hospitals, Chennai, and are expected to perform endodontic treatment on a variety of teeth belonging to the patients diagnosed to require root canal treatment. The aim of this study was to evaluate the quality of RCT performed by undergraduate (UG) dental students in Saveetha Dental College and Hospitals using radiographic records. MATERIALS AND METHODS This study was conducted among UG dental students. 107 post-operative radiographs of RCT done by the UG students were collected. Among these, 54 were maxillary anterior teeth, 15 were mandibular anterior teeth, 26 were mandibular premolars, and 12 were mandibular molars, respectively. Maxillary posterior was not included in this study since UGs are not allowed to do root canal treatment for maxillary premolars and molars. An aseptic technique with rubber dam isolation had been applied in all the cases, and working lengths were determined by means of radiographs. All the teeth had been instrumented with passive step-back technique using stainless steel K-files with 0.02 taper and irrigated with 2.5% sodium hypochlorite solution. Root fillings had been carried out with lateral compaction technique using gutta-percha. All the teeth had been temporarily filled and referred for permanent restoration. All the treatment steps were conducted under the supervision of teaching staff. Evaluation of the technical quality of RCT was based on the post-operative Radiograph (RVG) of each case. All RCTs were carried out using the step-back and lateral-compaction techniques with gutta-percha. The method of viewing the radiographs was standardized using RVG. The quality of the filling based on the length of the, density, and taper was assessed. Scores of 0, 1, and 2 were given by 2 experienced endodontists individually. The results were compared, and a final result was concluded. Parameters used to evaluate root canal were taken from a research article done in Taibah University. Strength of agreement was determined by calculation of the Kappa value (<0 = as no agreement, = as 2658

3 slight agreement, = as fair, = as moderate, = as substantial, and = as almost perfect agreement). Data collected were documented, and statistical analysis was done [Tables 1 and 2]. RESULTS The teeth were classified according to their location in the arches. The frequencies of teeth examined in this study are shown in Table 2. There were 54 maxillary and 53 mandibular teeth. All the maxillary teeth were anteriors. Among the mandibular teeth, 15 were anteriors, 26 were premolars, and 12 were molars. Quality of root canal filling according to length, density, and taper is shown in Table 3 and Figure 1. Perfectly length of the root filling was found in 36.27% of teeth, while 44% were length and 18.90% were un. Perfectly density was found in 16.77% of teeth, density was found in 60.41% of teeth, and un was found in 22.86% of teeth. Regarding the taper of the root canal filling, 19.30% were perfectly, 68.37% were, and 19.06% were un. The frequency of root canals with as significantly higher than the. Quality of RCT performed in the different type of teeth is shown in Table 4. The post-operative radiographs were divided into four different groups such as maxillary anteriors, mandibular anteriors, mandibular premolars, and mandibular molars. Since the radiographs were scored by 2 endodontics separately, the mean values of the scores were taken and compared. 25% of un root canal filling length was found in maxillary anteriors and mandibular molars while 6.5%, the least was found in mandibular anteriors. Perfectly density of root canal filling was found in mandibular anteriors which are 50% followed by mandibular premolars which are 42.30%, maxillary anteriors which are 36.10%, and mandibular molars which are 16.70%. Regarding the density of the root canal filling, the highest density was seen in maxillary anteriors and followed by mandibular anteriors, mandibular molars, and premolars. The density was seen in 28.85% of mandibular premolars followed by 14.85% of maxillary anteriors. The tapering of filling was found in 75% of mandibular molars, while 73.35% in mandibular anteriors, 71.30% in maxillary anteriors, and 53.85% in mandibular premolars. The perfectly tapering is seen in 53.80% of mandibular premolars. Since the post-operative radiographs were scored by 2 endodontists individually, the inter-rater reliability was done suing Cohen Kappa Test. Moderate Table 1: Criteria for assessment of radiographic quality of root canal filling Parameters Definition Score Length of root canal Density of root canal Taper of root canal Root filling ending>2 mm short of the radiographic apex (under filling) Root filling limited to the pulp chamber Root filling ending beyond the radiographic apex (over filling) Root filling ending at the radiographic apex (tip to tip) or 1 2 mm shorter than the radiographic apex Root filling ending mm short of the radiographic apex (adequate) Inhomogeneous root canal with several visible voids Root canal with only one visible void No void present in the root canal (adequate) Not consistently tapered from the apex to the coronal part (over or under shaped) Not enough taper Consistently tapered from the apex to the coronal part (adequate) and substantial agreement was found in maxillary anteriors while fair and moderate agreement was found in mandibular anteriors, moderate and almost perfect agreement was found in mandibular premolars, and moderate and substantial agreement was found in mandibular molars. Therefore, fair to almost perfect agreement was found in the scoring [Table 5]. 0 0 (un) 1 () 2 (perfectly ) 0 (un) 1 () 2 ( perfect) 0 ( not ) 1 () 2 (perfect) Table 2: Distribution of teeth in maxillary and mandibular arches Tooth type N (%) Maxillary 54 (50) Maxillary anterior teeth 54 (50) Mandibular 53 (49.5) Mandibular anterior teeth 15 (14) Mandibular premolars 26 (24.3) Mandibular molars 12 (11.2) Total 107 (100) 2659

4 Table 3: Overall quality of RCT according to length, density, and taper Length Density Taper un 18.90% 44% 36.27% 22.86% 60.41% 16.77% 19.06% 68.37% 19.30% RCT: Root canal treatment Table 4: Quality of RCT performed in different type of teeth Tooth type Mean length Mean density Mean taper Maxillary anterior 25% 38.85% 36.10% 16.70% 68.55% 14.85% 12.05% 71.30% 16.70% Mandibular anterior 6.70% 43.35% 50% 26.65% 66.65% 6.70% 20% 73.35% 6.70% Mandibular premolar 19.20% 38.50% 42.30% 23.10% 48.10% 28.85% 19.20% 53.85% 53.80% Mandibular molar 25% 58.30% 16.70% 25% 58.35% 16.70% 25% 75% 0 RCT: Root canal treatment Table 5: Inter rater reliability using Cohen kappa test Tooth type Length Density Taper Maxillary anterior Mandibular anterior Mandibular premolar Mandibular molar DISCUSSION In recent years, endodontics has been one of the fastest growing areas of dentistry. The use of modern tools, rubber dam, and the microscope in daily practice, significantly influence the quality and durability of treatment effects. This study aimed to evaluate the quality of root canal treatment carried out by UG students at Saveetha Dental College and Hospitals, Chennai. Post-operative RVG were used for assessment. The quality of root canal was evaluated. Researchers used different criteria for radiographic evaluation. Some used only length, [19,20] while others took the length and density [21,22] or in addition, even taper into consideration. [18,23,24] In this study, length, density, and taper of root canal filling were taken into consideration. In a Taiwanese population-based study, Chueh et al. [7] found that root canals with an adequate length of fillings were 61.7% while un fillings due to inadequate length were 25.0% and overfilling were 12.6%; 0.6% had no fillings in their root canals. As for homogeneous, 38.0% had. Peak et al. [25] studied the outcome of root canal fillings done by military general dentists in the Royal British Army. While 57% of the root fillings were definitely successful, the rest were probably successful (28%) and failures (15%). Boucher et al. [8] in his study among the French revealed a lower quality as only 21% of root fillings were reported to be technically. Our result was length of root canal filling in 44% of teeth. We also found that 60.41% of the teeth had homogenous root fillings and 68.37% of tapering of filling. Our results of length of root filling and were inferior to the technical quality of the studies cited above. These differences might be the results of differences in evaluation criteria, materials, educational system, methodology, and sample size between the present and previous studies. A study conducted by Ahmed et al. [26] assessing the quality of RCT conducted by house surgeons in Pakistan and found 58.9% of roots were acceptably obturated within 0 2 mm of the radiographic apex. A study was conducted in Senegal regarding the quality of root fillings. Only 17.7% of the roots fulfilled the criteria for an root canal 2660

5 Figure 1: Quality of root canal treatment performed in different type of teeth filling. [27] Nagaraja in his study concluded that the technical quality of root canal treatment performed by UG dental students was found to be better on the anterior teeth compared to the posterior teeth. [28] In this study, the highest rate of RCTs of perfectly length was for the mandibular anterior, and the lowest rate was for the mandibular molars. The highest rate of RCTs of perfectly density was for the mandibular premolars, and the lowest rate was for the mandibular anteriors. The highest rate of RCTs of perfectly tapering was for the mandibular premolars, and the lowest rate was for the mandibular molars. Modification of the endodontic curriculum and increasing the number of specialized staff members and training time for preclinical and clinical endodontic courses are important elements for improving student competency in endodontics. It will be useful to reevaluate the technical quality and procedural errors of RCTs performed by UG dental students in the future to determine the effects of educational program modifications. CONCLUSION The technical quality of root canal filling performed by UG dental students was mostly. However, to improve the quality of treatment performed by these students, the course of endodontic has to be improved at both preclinical and clinical levels. Newer techniques can also be introduced to improve the quality of RCT. REFERENCES 1. Stephen C. Pathways of the Pulp. United State of America: Mosby; Antonio N. Ten Cate s Oral Histology: Development, Structure, and Function. St. Louis, MI: Mosby; Shanon P. The Principles of Endodontics. Oxford, UK: OUP Oxford; Ilguy D, Ilguy M, Fisekcioglu E, Ersan N, Tanalp J, Dolekoglu S. Assessment of root canal treatment outcomes performed by Turkish dental students: Results after two years. J Dent Educ 2013;4:502e Moor R, Hulsmann M, Kirkevang LL, Tanalp J, Whitworth J. Undergraduate curriculum guidelines for endodontology. Int Endod J 2013;46:1105e European Society of Endodontology. Undergraduate curriculum guidelines for endodontology. Int Endod J 2001;34: Chueh LH, Chen SC, Lee CM. Technical quality of root canal treatment in Taiwan. Int Endod J 2003;36: Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J 2002;35: Segura-Egea JJ, Jiménez-Pinzón A, Poyato-Ferrera M, Velasco- Ortega E, Ríos-Santos JV. Periapical status and quality of root fillings and coronal restorations in an adult Spanish population. Int Endod J 2004;37: 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: Dummer PM. Comparison of undergraduate endodontic teaching programs in the United Kingdom and in some dental schools in Europe and the United States. Int Endod J 1991;24: Perˇsi c R, Kqiku L, Brumini G, Husetić M, Pezelj-Ribarić S, Brekalo Pršo I, et al. Difference in the periapical status of endodontically treated teeth between the samples of Croatian and Austrian adult patients. Croatian Med J 2011;52: Burke FM, Lynch CD, N ır Iord Ain R, Hannigan A. Technical quality of root canal fillings performed in a dental school and the associated retention of root-filled teeth: A clinical follow-up study over a 5-year period. J Oral Rehabil 2009;36: Moussa-Badran S, Roy B, Bessart du Parc AS, Bruyant M, Lefevre B, Maurin JC, et al. Technical quality of root fillings performed by dental students at the dental teaching centre in Reims, France. Int Endod J 2008;41: Khabbaz MG, Protogerou E, Douka E. Radiographic quality of root fillings performed by undergraduate students. Int Endod J 2010;43: Rafeek RN, Smith WA, Mankee MS, Coldero LG. Radiographic evaluation of the technical quality of root canal fillings performed by dental students. Aust Endod J 2012;38: 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: Tarim Ertas E, Ertas H, Sisman Y, Sagsen B, Er O. Radiographic assessment of the technical quality and periapical health of root-filled teeth performed by general practitioners in a Turkish subpopulation. ScientificWorldJournal 2013;2013:

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