Endodontic file separation and its management among dentists in Punjab, Pakistan: a cross-sectional study

The study aimed to find the incidence and awareness of endodontic instrument separation and its management among dental house officers, postgraduate trainees, demonstrators, consultants, and general dentists. Methods: This online questionnaire-based cross-sectional study was conducted with the approval of the IRB in private and public dental hospitals and dental clinics in Punjab. The authors developed the survey tool, which comprises 24 closed-ended items regarding demographics, the incidence of file separation, and awareness about its management. The data were analyzed using IBM SPSS version 24. The Chi-Square Test was used to compare percentages of categorical variables. Results: Postgraduate trainees experienced the most instrument separations (43.6%), made the most retrieval attempts (49.2%), and experienced the most secondary errors during retrieval (52.1%) (p<0.001). Around four out of ten respondents always informed the patients (39.6%) and department (41.6%) about errors. Manual files (69.8%), stainless steel files (75.8%), and short files (60.4%) were more frequently separated, and the most frequent cause was older fatigue files (57.7%). Manual files were more frequently broken in public dental institutes (p=0.003). Two-thirds of the file separations (72.5%) occurred during cleaning and shaping in the apical third of molars (65.1%), especially in mesiolingual canal (56.4%). Bypass attempt was the most common in symptomatic teeth (47.7%). Conclusions: Preventive approaches such as limiting file reuse and constructing a glide path can reduce the occurrence of file separation. Operators should be familiar with the number of uses of the instrument before fatigue and should be trained through workshops and refresher courses

Usage of Image-Enhancement Tools When Reading Radiographs Taken During Root-Canals Treatments' Procedures.

Objective: This study aimed at exploring the usage of radiographic image-enhancement tools in Saudi dental practice when interpreting radiographs taken for root-canal-treatments' (RCTs) procedures and the influencing factors. Methods: An online survey including questions related mainly to the usage of images enhancement tools and the reasons for no or low frequently usage was constructed. The survey was sent to 550 general dentists (GDs), randomly selected from the Saudi Dental Register, and all endodontists (185) in Saudi Arabia using the Google-Drive tool. A reminder email was sent two months later to encourage none-respondents to complete the survey. Data were analyzed using the Chi-square and Linear-by-Linear Association tests at p=0.05. Results: While the highest percentage of GDs (48.3%) never used the colour-coded tool, the highest percentage of endodontists (46.1%) used it sometimes (P<0.001). The majority (84.2%) used the contrast tool either generally (67.8%) or sometimes (16.4%) (P<0.001); with more endodontists (77.55%) than GDs (63.1%) (P=0.011). As participants experience decreased and the weekly performed cases increased, the trend of using this tool increased (P<0.05). While most GDs (67.6%) either never (46%) or few-times (21.6%) used the highlight tool, most endodontists (56.9%) either used it generally (34.4%) or sometimes (22.5%) (P<0.001). The majority (82.3%) were using the magnification tool either generally (55.1%) or sometimes (27.2%). The highest percentage (36.1%) was generally using the negative-view tool (P=0.045); with more endodontists (63.7%) than GDs (20.8%) (P<0.001). While "I don't know how to use it" was the dominant reason reported by GDs for not using most of the tools, lack of time was the dominant reason reported by endodontists (P≤0.001). Conclusion: The contrast and magnification were the most common used image-enhancement tools in Saudi dental practice. Endodontists reported greater preferences on using all images-enhancement tools than GDs. Unawareness and lack of time were the dominant reasons for not using the tools reported by GDs and endodontists, respectively. Further studies are required to determine the exact application for each tool and to investigate the impact of all image-enhancement tools on their diagnostic accuracy.

Modalities of using endodontic nickel-titanium rotary instruments and factors influencing their implementation in dental practice.

BACKGROUND: To establish the extent of using nickel titanium rotary instruments (NiTi-RIs), to identify reasons for using / not using NiTi-RIs, to explore usage modalities and to identify factors and measures that can increase implementation of NiTi-RIs in general dental practice. METHODS: Two pilot questionnaires were conducted on academic staff members at College of Dentistry, Taibah University, general dentists (GDs) and endodontists to finalise the questionnaire. A sample size was calculated considering the expected and minimum accepted response rates (60 and 48%, respectively) and a 99.9% Confidence Level. The online-questionnaire was sent to 600 GDs and all endodontists (175) working in Saudi Arabia. A reminder was emailed after 10 weeks to encourage non-respondents to complete the questionnaire. Responses, were collected and converted into numerical data which were analysed using the Chi-square test (p = 0.05). RESULTS: Significantly most respondents (71.9%) used NiTi-RIs (p < 0.001); with more endodontists (96.9%) than GDs (60%). Most users (62.5%) had been using NiTi-RIs for More than 3 years (p < 0001). The trend of using NiTi-RIs increased as participants' experience and the number of root-canal treatments performed per week increased (p = 0.021). While most respondents (45.3%) used NiTi-RIs because of faster root-canal preparation, the majority of non-users (85.3%) didn't do so because of high cost. The highest proportion (43.3%) reported better undergraduate education as the most important factor that can significantly increase NiTi-RIs usage. The majority (91.8%) prepared glide-path before using NiTi-RIs; especially with stainless steel hand-files (63.3%). CONCLUSIONS: NiTi-RIs are relatively well adopted in Saudi dental practice. However, better education, especially during undergraduate training and lower cost can increase their usage. Overall, clinicians showed good awareness of NiTi-RIs usage aspects which reflected on usage modalities.

Preferences of dentists and endodontists, in Saudi Arabia, on management of necrotic pulp with acute apical abscess.

BACKGROUND: This study aimed at investigating dental clinicians' preferences on management of necrotic pulp with acute apical abscess (NPAAA) cases. METHODS: Following an ethical approval and two pilot studies, an electronic survey was emailed to 400 general dental practitioners (GDPs) and 56 endodontists. The email explained the study's methods and assured that participants' identities and information given would remain anonymous and confidential. A reminder email was sent after eight weeks. Responses were collected and data were analyzed using the Chi-square test at p = 0.05. RESULTS: The majority of respondents (86.3%) would deal with NPAAA cases "differently" from vital-pulp ones (p < 0.001). More endodontists (40%) used two or three irrgants than GDPs (29.5%). Whilst the highest proportion of endodontists (29.7%) rarely prescribed antibiotics, the highest proportion of GDPs (26%) generally did so (p < 0.001). Whilst the highest proportion of GDPs (26.9%) over-instrumented the largest canal in the first visit, most endodontists (56.8%) performed complete cleaning & shaping (C&S) (p < 0.001). In cases of non-stopped exudates, whilst the highest proportions of endodontists would either let the patient wait till the exudates significantly reduce then continue their intended approach (40.5%) or insert ICMs and temporize the tooth (40.5%), the highest proportion of GDPs (30.8%) would insert only dry cotton pellet without temporizing the tooth (p = 0.002). Of those who would leave the tooth open if non-stopped exudates presents in the first visit, the majority (81.9%) would temporize the tooth if little exudates present after C&S (p < 0.001). CONCLUSIONS: Clinicians, especially GDPs, opted to treat teeth involved in NPAAA differently from those with vital-pulp, such as: were using different ICMs and irrigants, C&S to different apical size preparation. GDPs should improve their practice by implementing multi-irrigants protocol while C&S, limit prescribing antibiotics, perform complete debridement of the root canal system and not to leave the tooth open between visits. Clinicians, especially GDPs, relied on their own experiences in managing NPAA cases which necessitates scientific-based guidelines.

Accuracy of Cone-beam Computed Tomographic Image Interpretation by Endodontists and Endodontic Residents.

INTRODUCTION: Limited field cone-beam computed tomography (CBCT) imaging has become a modality frequently used by endodontists to evaluate the teeth and surrounding tissues of their patients. Accurate image interpretation is vital to obtain needed treatment information as well as to discern coincidental findings that could be present. The goal of this study was to determine the accuracy of CBCT volume interpretation when performed by endodontists and endodontic residents. METHODS: Eighteen deidentified limited field CBCT scans were obtained and evaluated by an oral and maxillofacial radiologist and an endodontist experienced in reading CBCT images. Their collective findings were combined as the "gold standard" of interpretation for this investigation. Using standard CBCT software, 4 practicing endodontists and 5 second-year endodontic residents evaluated each scan and recorded any notable findings and whether or not each scan warranted referral to a radiology specialist. Their interpretations were then compared with the gold standard to determine accuracy and any significant differences among the groups. RESULTS: The overall accuracy was 58.3% for endodontists and 64.3% for residents. Paired t tests showed no statistically significant differences in accuracy between the 2 groups for findings in teeth or in bone, but residents were significantly better for maxillary sinus findings. Endodontists agreed with the gold standard 38.9% of the time and residents 49.8% of the time on necessity of referral. The Cohen kappa coefficient showed moderate agreement between the groups. CONCLUSIONS: Endodontists and residents had similar accuracy in CBCT scan evaluation. More training and experience are warranted for both groups in order to maximize image assessment accuracy.

Regenerative Endodontic Procedures among Endodontists: A Web-based Survey.

INTRODUCTION: The protocols that endodontists implement for regenerative endodontic procedures (REPs) are unknown. The aim of this study was to examine current REP protocols among practicing endodontists in the United States. METHODS: A Web-based survey was sent to 4060 active members of the American Association of Endodontists (AAE). A total of 850 participants completed the survey, representing a 20.9% response rate. RESULTS: Responses indicated 60% reported having performed REPs; most performed 1 to 3 per year. The most commonly selected source (60.8%) for the clinical protocol was the "AAE Clinical Considerations for a Regenerative Procedure." Time constraints were the most common reason why 92.4% of respondents did not report their REP cases to the AAE.org database; additionally, 15.5% were unaware of it. Almost half (49.8%) of the participants reported they would attempt an REP on a patient of any age. The most commonly used irrigants were >3% sodium hypochlorite at the first appointment and EDTA at the scaffold formation appointment. As the intracanal medicament, 52.2% used calcium hydroxide, whereas 23.5% used triple antibiotic paste. At the scaffold formation appointment, 77.1% used a local anesthetic without a vasoconstrictor, and 94.3% used a blood clot as the scaffold. Mineral trioxide aggregate was the coronal barrier most often selected. Considering factors most likely to encourage the use of REPs in the future, 79.8% reported the availability of good candidates followed by 40.1% who desired better evidence. CONCLUSIONS: Based on the results of this survey, REP protocols appear to be heterogeneous and do not strictly conform to the "AAE Clinical Considerations for a Regenerative Procedure."

Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report of a National Survey.

INTRODUCTION: This study surveyed the antibiotic prescribing practices of endodontists, and data were compared with previous surveys conducted in 1994 and 1999. METHODS: A 17-question survey was sent via www.surveymonkey.com to 3000 active members of the American Association of Endodontists for responses about antibiotic prescribing practices and demographics. The data were analyzed using descriptive statistics, chi-square tests, and linear regression analyses. RESULTS: Six hundred eighty-six participants (22.86%) completed the survey. The most frequently prescribed antibiotics were amoxicillin (60.71%) followed by penicillin V (30.43%) and clindamycin for patients with allergies (95.4%). Respondents reported prescribing antibiotics for irreversible pulpitis with mild symptoms (1.75%), irreversible pulpitis with moderate symptoms (6.41%), necrotic pulp with symptomatic apical periodontitis (43.59%), chronic apical abscess without (10.50%) or with symptoms (29.74%), acute apical abscess (95.92%), avulsion (70.26%), endodontic surgery (41.69%), retreatment (silver point [23.76%] or gutta-percha [15.60%]), postoperative pain after instrumentation or obturation (12.39%), and perforation repair (5.98%). The type of practice (solo/group) and geographic region (Southeast) were significant predictors of increased antibiotic prescribing; 36.89% of respondents reported prescribing antibiotics that are not necessary, most commonly because of patient expectations. CONCLUSIONS: Since 1999, there has been a significant shift from prescribing penicillin V to amoxicillin as endodontists' first choice of antibiotic and a significant increase in the use of clindamycin for penicillin-allergic patients. Antibiotics continue to be prescribed in clinical situations for which they are typically not indicated, most commonly because of patient expectations. Regional differences in antibiotic prescribing practices by endodontists exist in the United States.

Influence of Cone-beam Computed Tomography in Clinical Decision Making among Specialists.

INTRODUCTION: Clinical information and diagnostic imaging are essential components of preoperative diagnosis. The aim of this study was to determine the influence of cone-beam computed tomographic (CBCT) imaging on clinical decision-making choices among different specialists (prosthodontists, endodontists, oral surgeons, and periodontists) in endodontic treatment planning. A secondary objective was to assess the self-reported level of difficulty in making a treatment choice before and after viewing a preoperative CBCT scan. METHODS: In accordance with the endodontic case difficulty guidelines of the American Association of Endodontists, 30 endodontic cases with varying degrees of complexity were selected. Each case included clinical photographs, digital periapical radiographs, and a small-volume CBCT scan. In the first evaluation, examiners were given all the information of each case, except the CBCT scan. Examiners were asked to select one of the proposed treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 30 cases with the additional information from the CBCT data. RESULTS: The CBCT scans only had a significant influence on the treatment plan when the endodontic case was classified as high difficulty (P < .05). The level of difficulty in choosing a treatment choice was significantly more difficult after viewing a preoperative CBCT scan (P < .05), with the exception of the endodontists (P = .033). After viewing the CBCT scan, the extraction option increased significantly (P < .05). CONCLUSIONS: CBCT imaging has a substantial impact on endodontic decision making among specialists, particularly in high difficulty cases.

General dentists', pediatric dentists', and endodontists' diagnostic assessment and treatment strategies for deep carious lesions: A comparative analysis.

BACKGROUND: There is a large variation among clinicians when managing deep carious lesions (DCLs). The purpose of this study was to assess general dentists' (GDs), pediatric dentists' (PDs), and endodontists' (EDs) diagnostic methods, clinical decision-making considerations, treatment strategies, and knowledge, behavior, and attitudes related to the diagnosis and treatment of DCLs. METHODS: A total of 175 GDs, 511 PDs, and 377 EDs responded to a nationwide Web-based survey. RESULTS: Most EDs (68%) and GDs (47%) practiced complete caries removal. PDs (31%) were more likely than GDs (12%) and EDs (4%) to remove carious tissues partially. Dentin hardness was the most important diagnostic criterion used during caries excavation (GDs, 90%; PDs, 72%; EDs, 88%). Only 30% of GDs, 17% of PDs, and 90% of EDs used diagnostic tests (for example, a cold test) when assessing pupal health. A substantial percentage of respondents considered endodontic treatment as a choice for treating DCLs in asymptomatic teeth in young patients (GDs, 40%; PDs, 30%; EDs, 40%). GDs rarely used a rubber dam when treating these lesions. CONCLUSIONS: Most respondents practiced complete caries removal until hard dentin was felt, using hardness as the primary excavation criterion, and did not use pulp diagnostic tests routinely before making decisions about treatment of teeth with DCLs. PRACTICAL IMPLICATIONS: Efforts should be made to translate the growing body of evidence supporting the use of conservative caries removal criteria to preserve pulpal health and tooth structure integrity when managing DCLs.

Differences in disinfection protocols for root canal treatments between general dentists and endodontists: A Web-based survey.

BACKGROUND: The purpose of this study was to determine whether differences exist in disinfection protocols between endodontists and general dentists. METHODS: The authors sent an invitation to participate in a Web-based survey to 950 dentists affiliated with the Spanish Board of Dentistry. Participants responded to 9 questions about irrigation protocols and other factors related to disinfection during root canal therapy. RESULTS: A total of 238 (25.05%) study participants successfully completed and returned the surveys. Among these participants, 50% were general dentists and 50% were endodontists. The authors found no statistically significant differences in respondents' first choice of an irrigant solution (that is, sodium hypochlorite), but they noted statistically significant differences in the protocols used by general dentists and by endodontists in relation to the concentration of sodium hypochlorite (P = .0003), the use and type of irrigant used to remove the smear layer (P = 5.39 × 10(-10)), the use of adjuncts to irrigation (P = 5.98 × 10(-8)), the enlargement of the apical preparation when shaping a necrotic tooth (P = .001), and the maintenance of apical patency throughout the debridement and shaping procedure (P = .04). CONCLUSIONS: General dentists and endodontists embrace different disinfection protocols. The results of the survey demonstrated that endodontists keep up to date with protocols published in the literature, whereas general dentists use protocols learned during their dental training. Both groups of clinicians should be aware of the importance of disinfection techniques and their relationship to treatment outcomes. PRACTICAL IMPLICATIONS: Controlling microorganisms during a root canal treatment, especially in cases with necrotic pulp, is essential to improve treatment outcomes. Clinicians should update their protocols and also consider referring patients to a specialist when their protocols are based on traditional techniques, especially in those cases with necrotic pulp.

Residents' Perceptions of the Graduate Endodontic Application Selection Process and Match.

INTRODUCTION: Anecdotal reports suggest that the application process for graduate endodontic programs in the United States and Canada is inefficient and may be perceived by applicants as being unfair. This survey examines residents' perceptions of the graduate endodontic application process and related issues. METHODS: A web-based survey consisting of 24 questions on the residents' perception of the graduate endodontic application process was developed and e-mailed to 403 graduate endodontic students in the United States and Canada. RESULTS: Of the 403 invited participants, 218 surveys were completed (53%). The responses were varied. Respondents were not overwhelmingly satisfied with the application/interview/selection process; 45% were satisfied or very satisfied, 25% were neutral, and 30% were dissatisfied or very dissatisfied. Only 39% indicated that they would have preferred a Match process. Eighty-two percent accepted the first program that offered a position, and 79% reported being satisfied or very satisfied with their choice of a program. CONCLUSIONS: Forty-five percent of endodontic residents were satisfied with the application/interview/selection process, and most would not have preferred a Match process.

A survey for endodontists in today's economy: exploring the current state of endodontics as a profession and the relationship between endodontists and their referral base.

INTRODUCTION: The purpose of this study was to assess the perceptions, referral trends, and practice patterns of practicing endodontists in the United States and any effect the recent economy may have had on these. METHODS: A 24-question survey was formulated and sent via www.surveymonkey.com to 3255 active members of the American Association of Endodontists. Overall, 875 participants completed the survey, a response rate of 26.9%. RESULTS: The average number of treatment cases per day was 5.7. Average work hours per week were 34.3 for men and 30.7 for women (P < .05). Among all treatment cases, 46% were nonsurgical retreatment, and 7.2% were apical surgical procedures. Procedural misadventure accounted for 10.8% of all treatment cases, with the most common referral reason being unable to locate canals (75.0%) followed by separated instruments (15.3%). Of all respondents, 49.9% performed regenerative endodontic procedures, and 7.7% placed implants. Among endodontists who practice in urban areas, 69.7% believed there were too many endodontists, and 50% have delayed their retirement plans because of recent economic impact, compared with their suburban and rural counterparts at 66.1% and 38%, 25.9% and 33.1%, respectively (P < .05). Fifty-nine percent of respondents were optimistic about the future of endodontics as a specialty, but those who have practiced more than 20 years were more pessimistic than those with less experience (P < .05). CONCLUSIONS: Recent economic impacts appear to have had an effect on the perceptions of active endodontists regarding practice success, the future of the specialty, and their retirement plans. Those who have been in practice longest (>20 years), practice in urban settings, and practice in a solo environment are most significantly affected.