Rdiogrphic evlution of the technicl qulity of undergrdute endodontic competence cses in the Dulin Dentl University Hospitl: n udit Précis: An udit exmining the technicl qulity of undergrdute endodontic competence cses in the Dulin Dentl University Hospitl reveled fvourle results compred to enchmrk studies, ut identified res for improving qulity. Mohit Kumr Gret Western Hospitls NHS Foundtion Trust Gret Western Hospitl Mrlorough Rod Swindon United Kingdom Henry F Duncn Lecturer nd Consultnt in Endodontics Division of Restortive Dentistry nd Periodontology Dulin Dentl University Hospitl Trinity College Dulin Lincoln Plce Dulin Irelnd Address for correspondence Henry F Duncn Dulin Dentl University Hospitl T: 01-612 7356 E: Hl.Duncn@dentl.tcd.ie Astrct Purpose: The im of this udit ws to evlute the technicl qulity of undergrdute de novo endodontic competence cses in the Dulin Dentl University Hospitl (DDUH) compred to Europen stndrds. 1,2 Mterils nd methods: A rdiogrphic nlysis of the numer of cnls in student competence cses (completed 2009-2010) tht met the ccepted technicl criteri for n idel root cnl tretment ws crried out. The enchmrk ws formulted using ccepted Europen guidelines. Severl technicl fctors were nlysed including the picl extent of oturtion (within 2mm of rdiogrphic pex), the presence of voids, technicl errors nd the presence of untreted roots. One hundred nd nineteen root cnls were initilly selected in 78 teeth; however, five teeth were excluded from nlysis s the postopertive rdiogrph ws either missing or not dignostic. Results: Single-rooted teeth demonstrted voids in 36% of root fillings, nd 69% were filled to within 2mm of the pex nd there were no detectle technicl deficiencies. Multi-rooted teeth demonstrted voids in 38% of root fillings; 60% were filled to within 2mm nd 94% of cnls demonstrted no devition from the originl cnl. Comined results demonstrted tht 49% of ll the single-rooted teeth nd 17% of ll the multi-rooted teeth were cceptle within the technicl prmeters identified in the guidelines. Conclusions: Anlysis of individul technicl criteri reveled res in which the qulity ws cceptle nd others in which it could e improved. Although the overll results ppered poor, they were similr to previous studies of the technicl qulity of undergrdute root cnl tretment. 2-5 Journl of the Irish Dentl Assocition 2012; 58 (3): 162-166. Introduction The im of root cnl tretment is to chemomechniclly clen nd oturte the root cnl system to prevent or cure picl periodontitis. 6 Root cnl tretment is indicted if the pulp hs irreversile disese or is necrotic. It is essentil to tke pproprite rdiogrphs efore, during nd fter the procedure. Every prctitioner is required to retin record of the completed tretment in the form of postopertive rdiogrph. The technicl stndrd of root cnl tretment hs een demonstrted to e closely relted to success 2 nd proxy ssessment of technicl success is the postopertive rdiogrph of the completed root cnl tretment. 7 Technicl guidelines relted to preprtion nd oturtion Ferury/Mrch 2012 162 : VOLUME 58 (1)
pulished y Sjögren (1990) 2 nd the Europen Society of Endodontology (2006) 1 re ccepted s Europen stndrds. It is importnt to mke the distinction etween udit nd reserch, udit eing designed to exmine current prctice ginst recognised enchmrks of est prctice. It is not intended to e hypothesisdriven or to generte dt s prt of n originl scientific rticle. After the initil udit is completed n ction pln is generted, implemented nd, fter designted time period, re-udited to complete the udit loop. The im of this udit ws to estlish the technicl qulity of root cnl tretment performed y undergrdute dentl students in the Dulin Dentl University Hospitl (DDUH). Mterils nd methods The udit ws crried out in order to ssess the technicl qulity of undergrdute root cnl tretment compred to ccepted Europen guidelines. After suitle udit re ws identified, it ws discussed, proposed nd pproved y the DDUH clinicl udit committee. The trget smple for the udit ws single- nd multi-root competence cses treted y undergrdute students. All third-, fourth- nd fifth-yer undergrdute students in DDUH complete competence in oth single- nd multi-root de novo endodontic tretments, which they must pss in order to proceed with their studies. Students re given permission to proceed with the competence y senior memer of stff, fter successful completion Appendix 1: Pro form sheet for dt collection. Nme: Ptient no.: Tooth no.: Root: Presence of voids Within 0-2mm of rdiogrphic pex Over-oturted Under-oturted (>2mm short of rdiogrphic pex) All roots oturted Prepred cnl contins the originl cnl No extrusion Seprted instrument Yes No Undignostic rdiogrph(ur)/no rdiogrph ville of two supervised pre-competence cses in single- nd multi-root endodontic tretments, respectively. These competence cses re treted under the supervision of prt-time techer nd re pproved fterwrds y senior stff memer; however, they re designed to e n ssessment of the student s endodontic ility nd therefore should e essentilly unssisted. During the udit ll of the competence forms were retrieved for single- nd multi-rooted endodontic tretments completed in DDUH in the yer 2009-2010. A totl of 46 single- nd 32 multi-rooted competence cses were identified for the purpose of this udit. The single roots were nlysed per tooth, while multi-rooted cnls were initilly nlysed individully nd therefter comined per tooth. Premolr teeth pper in oth single- nd multi-root ctegories, depending on the numer of roots tht the chosen tooth exhiited. It is estlished within the DDUH guidelines tht lthough premolr teeth re permissile s prt of the multi-root competence, molr teeth should e used if ville. The root cnl instrumenttion (in the oserved period) ws generlly crried out y trditionl hnd instrumenttion using step ck technique; however, hnd nd rotry nickel titnium (s result of new teching protocol) ws employed in selected lter cses. The teeth were oturted with Interntionl Orgnistion for Stndrdistion (ISO) corresponding gutt-perch points using lterl condenstion technique. A pro form sheet (Appendix 1) ws designed to id nlysis using criteri from the Europen enchmrk stndrds, 1,2 nd the Europen Society of Endodontology (2006) 1 consensus pper, supplemented y the seminl endodontic outcome study y Sjögren (1990). 2 From the stndrds, the relevnt technicl indictors were identified nd the idel stndrd defined. The idel root cnl oturtion should terminte within 0-2mm of the rdiogrphic pex, hve no evidence of voids, should e present in ll the root cnls, nd should e contined within the originl cnl ntomy with no evidence of picl devition, cnl ledging or strightening. 1,2 Postopertive rdiogrphs tken from ech competence cse, using the prlleling technique, were nlysed y two ssessors (nonconsultnt hospitl doctors NCHDs) nd the relevnt dt collected on the pro form sheet. If there ws disgreement etween the NCHDs, third ssessor (Consultnt) ws sked to djudicte; there ws inter-oserver disgreement in five cses. All single-rooted nd the mjority of multi-root postopertive rdiogrphs were ville electroniclly nd were ssessed using the mesuring softwre in the Dimxis system (Dimxis, Plnmec; Helsinki, Finlnd). Seven of the multi-rooted cses hd old style pper chrts, which were otined to ccess their respective rdiogrphs. From these chrts, rdiogrph films were ssessed using n x-ry viewox nd the distnce to the pex mesured y conventionl metric ruler. Results Single-rooted teeth One of the 46 cses nlysed (2%) hd no rdiogrph ville nd ws eliminted from the udit. In one further cse the rdiogrph ws deemed to e undignostic nd ws not included in the nlysis. Of VOLUME 58 (3) : 163
FIGURE 1: Preopertive peripicl rdiogrph of tooth 45, demonstrting coronl rdiolucency indictive of extensive cries. This premolr hd one cnl nd ws considered suitle for the single-root competence test. FIGURE 1: Postopertive peripicl rdiogrph of the 45, demonstrting root cnl filling tht ws under-extended (>2mm from the rdiogrphic pex) nd contined voids. The decision ws mde to re-tret this tooth, efore completion of the competence. TABLE 1: Percentge of cnls tht did not demonstrte ny voids rdiogrphiclly nd re oturted to within 2mm of the pex in single- nd multi-rooted teeth. 100 90 80 70 60 50 40 30 20 10 0 % No voids 0-2mm pex Single-root Multi-root the reminder, 64% of the root-filled cnls hd no detectle voids, while 36% of the rdiogrphs demonstrted voids in the cnl (Figures 1 nd ). In 69% of cses the root filling ws within 2mm of the rdiogrphic pex, in 16% it ws over-extended nd in 15% it ws under-extended (Figure 1) (Tle 1). All of the rdiogrphs nlysed reveled tht the root cnl filling mteril ws contined in the originl cnl. When the investigted fctors (voids, length, procedurl errors) were comined, 49% of teeth were considered to meet the technicl stndrd for single-root competence cses (Figures 2 nd ) (Tle 1). Multi-rooted teeth A totl of 73 cnls were ssessed from 32 teeth. In one cse the rdiogrph ws undignostic nd in two cses there ws no postopertive rdiogrph ville; these were not included in the nlysis. A totl of 62% of the cnls hd no detectle voids, while 38% demonstrted voids. In 60% of roots the gutt-perch ws FIGURE 2: Preopertive peripicl rdiogrph of tooth 23, demonstrting n picl rdiolucency indictive of picl periodontitis. This cnine ws considered suitle for the single-root competence test. FIGURE 2: Postopertive peripicl rdiogrph of the 23, demonstrting root cnl filling contining no voids, ut evidence of slight overfilling nd extrusion of gutt-perch/seler. FIGURE 3: Preopertive peripicl rdiogrph of tooth 47, demonstrting n picl rdiolucency indictive of picl periodontitis ssocited with the 46 nd 47. This second molr tooth ws considered suitle for the multi-root competence test. FIGURE 3: Postopertive peripicl rdiogrph of the 47, demonstrting root cnl filling in the mesil root cnls tht contined no voids, ws oturted to within 0-2mm nd ws contined within the originl cnl ntomy. The distl root filling, lthough not contining ny voids, hd cler evidence of gutt-perch/seler extrusion, nd ws clssed s overfilled. This designted tooth 47 s unstisfctory for the purposes of this technicl udit. within 0-2mm of the rdiogrphic pex, in 9% it ws over-extended (Figures 3 nd ) nd in 31% of the roots it ws under-extended (Tle 1). A totl of 94% of cses demonstrted the prepred cnl contining the originl cnl nd 6% of the cnls were devited from the originl cnl. When the technicl fctors were comined per cnl, 28 of the 73 cnls (38%) were considered stisfctory. When the individul cnls of multi-rooted teeth were collted, 45% of teeth hd no detectle voids. A totl of 95% of teeth hd ll roots oturted on postopertive rdiogrphs; 5% of teeth hd one or more roots tht hd een missed. When technicl indictors were comined s multi-rooted teeth, five teeth from 29 teeth (17.5%) were considered stisfctory (Figures 3 nd ) (Tle 2). 164 : VOLUME 58 (3)
100 90 80 70 60 50 40 30 20 10 0 % TABLE 2: Percentge of single- nd multi-rooted teeth tht stisfy ll technicl prmeters. Single-root Multi-root Finlly, when premolrs (single- nd multi-root) re nlysed seprtely, 10 root cnls were treted from eight teeth. A totl of 80% hd no detectle voids, while 20% demonstrted voids. In 80% of roots the root filling ws within 0-2mm of the rdiogrphic pex; in 20% it ws short. There were no premolr cses demonstrting devition of the prepred cnl. Discussion The im of this udit ws to investigte the technicl qulity of root cnl filling y evlution of postopertive intr-orl rdiogrphs. Current Europen guidelines were used s enchmrk for the ssessment. 1 This udit ws not designed to mesure the success of root cnl tretment s tht would require extensive clinicl exmintion nd follow-up. However, technicl qulity is generlly considered to e proxy mrker s there is positive correltion etween high technicl qulity nd endodontic outcome. 7 Undergrdute competence cses were selected s they reflect y regultion, student s own work. It is lso implicit tht the cses were deemed cceptle to pss the competence, s only successful cses were nlysed within the udit. Therefore, it is possile tht this stndrd of tretment my not e representtive of non-competence cses. Therefore, this udit does not represent ccurtely the technicl stndrds of ll undergrdute root cnl tretment in the DDUH. The qulity of root cnl tretment ws ssessed in clssic Swedish university-sed study in which the tretment ws similrly crried out y undergrdute students under supervision. 2 The purpose of their study ws to determine the fctors tht ffect the long-term success of endodontic tretment. When ssessing the picl level of oturting mteril in 204 cses, 62% were within 0-2mm of the rdiogrphic pex. A totl of 11% of ll the teeth were underoturted, nd 27% were over-oturted. 2 The presence or sence of voids ws not ssessed in the study. The cses tht were oturted to within 0-2mm of the rdiogrphic pex were ssocited with significntly etter outcome thn cses tht were either under- or over-oturted. The conclusions stressed the importnce of good length control nd oturtion to within 2mm of the pex for longterm success. The results from Sjögren s clssic study were similr to the results for extent of root cnl filling otined in this udit. In this current udit, 67% of the single-rooted teeth nd 60% of the roots in multi-rooted teeth were oturted to within 0-2mm of the rdiogrphic pex. Possile resons for under-oturtion include preprtion errors or olitertion of the cnl preventing instrumenttion of the entire cnl, while possile resons for overoturtion include over-instrumenttion, poor length control or excessive pressure during oturtion. 7 Other studies exmining the technicl qulity of undergrdute root cnl tretment hve een pulished. 3-5,8-11 Within Irelnd, similr study investigted the technicl qulity of undergrdute tretment on single-rooted teeth in Cork University School nd Hospitl; 3 the results of tht study compre closely with this udit s 70% (69%) of the teeth were oturted to within 0-2mm. The overll numer of teeth tht were considered cceptle ws higher in the Cork study, 3 principlly ecuse of smller numer of cnls contining voids (10%) thn in the current study (36%). It is not cler wht ccounts for this difference; perhps it is due to stricter evlution criteri in the current study or reflects difference in pre-clinicl/clinicl teching etween the two schools. An udit of undergrdute root cnl tretment within the UK reveled tht only 13% of cses were deemed stisfctory in terms of rdiogrphic qulity of the root filling nd the distnce from the rdiogrphic pex. 4 The uthors concluded tht the technicl qulity of undergrdute student root cnl tretment ws poor. 4 Although our study compres fvourly with the UK udit, the criteri Hyes et l. (2001) used for rdiogrphic ssessment were slightly different nd could ccount for t lest some of the difference. Studies from other countries revel rnge in the qulity of technicl root cnl fillings performed y undergrdute students. 5,8-11 A Greek study reported stisfctory root fillings in 71% of nterior teeth nd 39% of molr teeth; however, the multi-rooted teeth were judged per cnl nd not per tooth, which infltes the reported results. 5 A study from Turkey reveled 33% of teeth to e techniclly dequte, 8 seprte Greek study reported 55% of teeth techniclly dequte, 9 nd study from Jordn reported 47% of root cnl fillings to e stisfctory, 10 while Sudi Arin study reported just 23% of cses to e stisfctory. 11 Severl findings re common to these studies, with the technicl qulity of undergrdute root cnl tretment eing generlly poor nd single-rooted teeth eing completed stisfctorily more often thn multi-rooted teeth. 5,9,10 These fetures re lso evident in the current udit. The Europen Society of Endodontology (2006) 1 consensus report sttes tht the postopertive rdiogrph should revel root tht is completely filled, with no spces etween the filling nd the cnl wll. For single-rooted nd multi-rooted teeth per cnl in the current study, 64% nd 62% of cses did not contin voids, respectively. When ssessing per tooth in multi-rooted cses, there ws mrked decrese to 45% of teeth contining no voids. It cn e speculted tht there is n incresed likelihood of otining voids in the roots of multi-rooted teeth due to the undergrdute chllenge of the lterl condenstion oturtion technique in posterior teeth. VOLUME 58 (3) : 165
All single-rooted teeth nd 94% of the roots of multi-rooted teeth hd their prepred cnls contined within the originl cnls. This devition of prepred cnls from originl cnls, only in multi-rooted teeth, would e expected ecuse of the presence of curved cnls in molr teeth, which re recognised to e more chllenging to instrument effectively. When technicl fctors were comined, 49% of single-rooted teeth nd 17% of multi-rooted teeth were considered stisfctory. This ppers low ut cn e rtionlised, prticulrly in multi-rooted teeth where three to four cnls re comined into one tooth. As the presence of voids ws reltively high in this udit this skews the dt, incresing the numer of teeth tht re techniclly uncceptle. Interestingly, voids nd oturtion within 0-2mm results were very similr for single- nd multirooted teeth. Unfortuntely, lthough the presented results re poor, they compre or re superior to other results in similr studies in the literture. 3,4,10,11 A drwck when ssessing mndiulr molrs ws visulising ll the root cnls on the rdiogrph, s mny overlpped, mking effective seprtion impossile. This ws limittion in ssessing these cnls, so for the purpose of this udit the mesil cnls were considered s one cnl. Rdiogrphic prllx methods nd ltered horizontl ngultion of the x-ry tue hed could ssist in seprting the mesil cnls in these cses, which revels n importnt re for future student teching. It is interesting to highlight the unvilility of two postopertive rdiogrphs, one electronic for single-rooted nd one trditionl film for multi-rooted teeth. It is possile tht the wet film ws misplced, while this is unlikely with the electronic version. It is hoped tht the introduction of the phosphor plte system will reduce the incidence of missing rdiogrphs in the DDUH. Finlly, necdotlly the most frequent tooth chosen for competence for single-rooted teeth ws the upper centrl incisor, which perhps implies tht trum is mjor source of ptients for competences within teching hospitl. A wide rnge of multi-rooted teeth were used s competence, with lower first molrs eing the most commonly treted teeth. Conclusions nd ction pln This udit demonstrtes fvourle results for termintion of root cnl filling when compred to the enchmrk stndrd. The desired im to chieve oturtion to within 2mm of the rdiogrphic pex cn e chieved y creful instrumenttion nd perhps improved y the continued introduction of new technologies. A specilist s opinion (if ville) should e sought without dely if the cnl ppers to e oliterted during instrumenttion to void lockge nd potentil under-oturtion. However, in terms of other technicl mrkers, there is need to highlight deficiencies tht cn e improved, s the overll result for techniclly cceptle root cnl tretment ws poor. A totl of 63% of single-rooted cses nd 60% of multi-rooted cses were considered cceptle in terms of no voids; this ws considered too low. There is need to improve oturtion techniques to hve the root completely filled with no spces etween the filling nd the cnl wll. 1 As result of the findings, the following ction pln ws decided t the DDUH udit committee: 1. Voids cn e reduced y the introduction of use of greter tpered gutt-perch points nd the need for lterl condenstion should e minimised. These gutt-perch points hve een introduced to the undergrdute curriculum recently nd should reduce the risk of void formtion. 2. The use of nickel titnium instruments should e considered in ll undergrdute cses for improved length preprtion, reduced likelihood of lockge nd oturtion to within 0-2mm of the rdiogrphic pex. These instruments re thought to improve preprtion nd prevent the loss of length during preprtion. 3. Apex loctors should generlly e used for ccurte working length determintion nd confirmed with rdiogrph. These re to e used routinely within the clinics to improve the length of instrumenttion nd oturtion. 4. Use of n electronic rdiogrph dtse in the DDUH should minimise the risk of rdiogrphs tht should e retined eing misplced. 5. This udit should e repeted fter two yers when the integrtion of the ction pln resulting from this udit hs come into function. References 1. Europen Society of Endodontology. Qulity guidelines for endodontic tretment: consensus report of the Europen Society of Endodontology. Int Endod J 2006; 39: 921-930. 2. Sjögren, U., Hgglund, B., Sundqvist, G., Wing, K. Fctors ffecting the long-term results of endodontic tretment. J Endod 1990; 16: 498-504. 3. Lynch, C.D., Burke, F.M. Qulity of root cnl fillings performed y undergrdute dentl students on single-rooted teeth. Eur J Dent Educ 2006; 10: 67-72. 4. Hyes, S.J., Gison, M., Hmmond, M., Brynt, S.T., Dummer, P.M.H. An udit of root cnl tretment performed y undergrdute students. Int Endod J 2001; 34: 501-505. 5. Khz, M.G., Protogerou, E., Douk, E. Rdiogrphic qulity of root fillings performed y undergrdute students. Int Endod J 2010; 43: 499-508. 6. Nir, P.N. On the cuses of persistent picl periodontitis: review. Int Endod J 2006; 39: 249-281. 7. Whitworth, J. Methods of filling root cnls: principles nd prctices. Endod Topics 2005; 12: 2-34. 8. Er, O., Sgsen, B., Mden, M., Cinr, S., Khrmn, Y. Rdiogrphic technicl qulity of root fillings performed y dentl students in Turkey. Int Endod J 2006; 39: 867-872. 9. Eleftheridis, G.I., Lmrinidis, T.P. Technicl qulity of root cnl tretment nd detection of itrogenic errors in n undergrdute dentl clinic. Int Endod J 2005; 38: 725-734. 10. Brrieshi-Nusir, K.M., Al-Omri, M.A., Al-Hiyst, A.S. Rdiogrphic technicl qulity of root cnl tretment performed y dentl students t the Dentl Teching Center in Jordn. J Dent 2004; 32: 301-307. 11. Blto, H., Al Khlifh, S., Al Mugirin, S., Al Dee, M., Al-Mdi, E. Technicl qulity of root fillings performed y undergrdute students in Sudi Ari. Int Endod J 2010; 43: 292-300. 166 : VOLUME 58 (3)