Modern endodontic practices among dentists in India: A comparative cross-sectional nation-based survey.

INTRODUCTION: More than 41,000 root canal treatments (RCTs) are performed every day and about 25 RCTs are performed every week by an endodontist. The success rate of endodontic treatment ranges between 86% and 98%; however, the failure rates cannot be ignored which can range up to 20% of the treated cases due to a varied number of reasons including incorrect adoption of working techniques and usage of inappropriate materials. The present study aimed at comparing the practices of various levels of dentists toward RCT in their daily practice.
METHODOLOGY: A cross-sectional, descriptive, questionnaire-based study was conducted among the dental practitioners who have completed the Masters of Dental Surgery (MDS) curriculum in India and postgraduate students in various dental colleges in India. The sample size was achieved to be 1601 at the completion of the study. The response rate for the study was 80.05%. All the dentists practicing RCT either in the clinic or in the college and willing to participate in the study were included in the study. A self-structured questionnaire was used as study tool. SPSS was used to analyze the data.
RESULTS: A total of 26.7% of the PG students (endodontists) used rubber dam. Majority of the dentists preferred hand instruments (62.36%) over rotary. Almost half (53.09%) of the postgraduates belonging to other branches reported to prescribe drugs.
CONCLUSION: The present study showed a varied profile of the dentists with most of them following the basic protocols and techniques of international standards. Copyright:

INTRODUCTION

As per 2019 UN data, the population of India is projected to be 1.37 billion.[1] In India, a total of 93,332 dentists are currently practicing.[2] According to the global statistics by the WHO, we see a ratio of just one dentist/10,000 people in urban areas and one dentist/150 K people in rural India.[3] The sphere of endodontic evolves each day with the ordination of the latest materials and equipment, and therefore, all practicing dentists are exposed to a plethora of choices in terms according to the same. Root canal treatment (RCT) is a predominant treatment option in the field of endodontic, which is easily chosen as the protocol of choice. More than 15 million RCTs are performed a year.[4] More than 41,000 RCTs are performed every day and about 25 RCTs are performed every week by an endodontist.[5] The success rate of endodontic treatment ranges between 86% and 98%; however, the failure rates cannot be ignored which can range up to 20% of the treated cases due to a varied number of reasons including incorrect adoption of working techniques and usage of inappropriate materials.[6] This survey thus is being carried out to throw some light on whether the available techniques and the materials are being adopted correctly or incorrectly by the dentists in India and to draw a comparison with global practices. This study would help in filling up of the lacunae in daily practice along with imparting better and standardized treatment and care toward patients. The aim of the study is to compare the practices toward RCT by various levels of dentists in India.

METHODOLOGY

A cross-sectional, descriptive, questionnaire-based study was conducted among the dental practitioners who have completed the Masters of Dental Surgery (MDS) curriculum in India and postgraduate students in various dental colleges in India from November 2019 to March 2020.

Sample population

Dental practitioners were divided into four different groups: MDS in endodontia, MDS in other branches, postgraduate students in endodontics, and postgraduate students of other branches. The sampling frame comprised 2000 dentists who were contacted by the investigator through e-mail to complete the questionnaire. A total of 1601 dentists participated in the study. The response rate for the study was 80.05%. All the dentists practicing RCT either in the clinic or in the college and willing to participate in the study were included.

Sampling

A multi-stage proportionate cluster random sampling method was used. India was divided into five different zones: Eastern zone, Western zone, Southern zone, Northern Zone, and Central zone. The states falling in the individual zones were shortlisted. The sampling was done in more than one level: national and state levels to improve the representativeness of the sample. The list of colleges in each state was noted. Due to the uneven distribution of the dental colleges in the zones, proportionate random sampling method was used. The ratio of dental colleges was derived. Colleges with MDS courses were enlisted and using the lottery method; individual colleges were randomly selected. The colleges were considered clusters from which the sample population was selected. The dentist population was most in the southern zone and least in the eastern zone. Dental, the list of all practitioners who have completed MDS, was attained from individual state dental council, and the list of the postgraduate students was shortlisted contacting the heads of the selected colleges.

Sample size calculation

The sample size was calculated using G*Power version 3.1.9.7 (Erdfelder, Faul, & Buchner, 1996), and a minimum sample size of 625 dentists were attained.

Questionnaire

A self-structured questionnaire was made in the form of Google Forms and distributed after validation. The questionnaire consisted of 27 closed-ended, both pretested and self-framed, self-explanatory questions on “RCT procedure.” The questionnaire was divided into three sections: first section consisting of questions regarding pretreatment usage of equipment; second part regarding the preferred type of instrumentation and techniques “during RCT,” and third part regarding concerning drug regimen “post-RCT.” A total of 28 questions were included. The reliability coefficient for questions in each of the subscale was calculated using Cronbach's alpha (α = 0.97) which indicated a high internal consistency. The content and the construct validation were done by a group of experts: one public health dentist, one internal endodontist, two external endodontist, and one biostatistician. The face validation was done on a group of participants fulfilling the eligibility criteria during the pilot study. The kappa statistic value was calculated to be 0.74 denoting substantial agreement.

Pilot study

Before data collection, a pilot study was conducted on forty participants from a similar study population other than the population selected to assess the uniform interpretation of the questions. The pilot study sample was not included in the main study. Ethical clearance was obtained from the Institute Ethics Committee (KIMS/KIIT/IEC/14/2019). All participants digitally signed informed consent before attempting the questionnaire. At the completion of the pro forma, a copy of their responses was mailed to the respective participants.

Data were imported from Google Docs into MS EXCEL Version 2016. The coding of the responses was done and statistically analyzed using IBM SPSS Statistics for Windows, Version 24.0. IBM Corp., Armonk, NY, USA program to draw the inferential statistics (means and standard deviation) between the various groups, gender, and procedures used and compare the same using the Chi-square test. P < 0.05 was considered to be statistically significant.

RESULTS

A total of 1601 dental professionals participated in this study from the various parts of the country. The mean age group of the participants was 27.25 ± 05.578. Table 1 shows the distribution of the demographic variables. Table 2 denotes the variations of the practice methods among the groups. It was reported that the majority of the participants did not use rubber dam and occasional use of rubber dam was observed among the endodontists group (50.80%) which was statistically significant (P < 0.0001). The majority of the dentists preferred hand instruments (62.36%) over rotary or combined and was highest among the postgraduate students belonging to other branches, which was statistically significant (P < 0.0001). Single cone technique was the most preferred technique for obturation and a statistically significant practice was observed among the endodontists group. Almost half (53.09%) of the postgraduates belonging to other branches reported to prescribe drugs, and the difference was statistically significant (P = 0.049). Graph 1 shows the variations of the practice among the different groups of dental practitioners included for the study. Table 3 reports the results of multiple logistic regressions where comparison of the endodontists with the other groups has been made and was found to be statistically significant.

Table 1

Demographic characteristics of the study sample

Variable	n (%)
Gender
Male	628 (39.2)
Female	973 (60.8)
Type of practice
Private	915 (57.3)
Academic	526 (32.7)
Both	160 (10.0)
Years of practice
<1	749 (46.9)
2-5	670 (41.9)
5-10	96 (6.1)
>10	86 (5.1)
Type of tooth
Single-rooted	156 (9.3)
Multi-rooted	1445 (90.7)
Average number of RCTs per week
0-5	693 (43.4)
5-10	486 (30.3)
>10	422 (26.3)

RCTs: Randomized controlled trail

Table 2

Comparison between the groups

Variable	PG endo, n (%)	PG other branch, n (%)	MDS other branch, n (%)	MDS endo, n (%)	χ2	P
Use of rubber dam
Always	42 (8.6)	51 (8.9)	78 (17.29)	60 (24.00)	94.55	<0.0001*
Occasional	97 (26.7)	197 (35.81)	220 (48.78)	127 (50.80)
Don’t use	211 (64.7)	302 (54.9)	153 (33.92)	63 (25.20)
Preferred method of instrumentation
Hand instruments	100 (28.57)	343 (62.36)	62 (13.74)	22 (8.80)	43.02	<0.0001*
Rotary	60 (17.14)	69 (12.54)	226 (50.11)	116 (46.4)
Combination	190 (54.28)	138 (25.08)	163 (36.14)	112 (44.80)
Method of obturation
Lateral	216 (61.71)	227 (41.27)	105 (23.28)	38 (15.2)	163.64	<0.0001*
Vertical	62 (17.71)	84 (15.27)	24 (5.30)	20 (8)
Core carrier	16 (4.57)	37 (6.72)	26 (5.70)	0 (0.00)
Single cone	56 (16)	201 (36.54)	296 (65.63)	192 (76.80)
Drug regimen
Pre	108 (30.85)	153 (27.81)	103 (22.8)	49 (19.6)	24.17	0.049*
Post	62 (17.77)	104 (18.72)	111 (24.61)	45 (18.00)
Both	180 (51.42)	292 (53.09)	237 (52.54)	156 (62.40)

MDS: Masters of dental surgery, PG: Postgraduate *The difference between statistically significant and highly statistically significant is to quantify whether the result is by chance or because of some factor of interest

Graph 1

Group-wise comparison of the variables

Table 3

Multiple logistic regression when masters of dental surgery endo is compared with the other groups

Reference category is MDS endo	Significant	Exp(B)	95% CI for Exp(B)
			Lower bound	Upper bound
PG endo
Use rubber dam for endodontic treatments?
Always	0.012*	0.276	0.101	0.757
Occasional	<0.0001**	0.080	0.044	0.145
Don’t use
Preferred technique of instrumentation for root canal treatment
Hand instruments	0.007*	3.839	1.435	10.273
Rotary	0.865	0.932	0.414	2.098
Combination	.	.	.	.
Obturation technique that you prefer
Lateral	<0.0001**	20.435	10.793	38.690
Vertical	<0.0001**	36.559	10.284	129.968
Core carrier	0.993	219835379.108	0.000	c
Single cone
When do you prescribe the drug regimen (analgesics, anti-inflammatory, antibiotic)
Pre	0.458	0.781	0.407	1.500
Post	0.007*	2.676	1.309	5.472
Both
PG other branch
How often do you use rubber dam for endodontic treatments?
Always	<0.0001**	0.174	0.070	0.432
Occasional	<0.0001**	0.121	0.071	0.204
Don’t use
Preferred technique of instrumentation for root canal treatment
Hand instruments	.061	2.486	.958	6.450
Rotary	.593	.827	.411	1.663
Combination	.	.	.	.
Obturation technique that you prefer
Lateral	<0.0001**	6.042	3.419	10.680
Vertical	<0.0001**	24.123	7.400	78.641
Core carrier	0.993	285328607.353	0.000	c
Single cone
When do you prescribe the drug regimen (analgesics, anti-inflammatory, antibiotic)
Pre	0.290	0.732	0.411	1.304
Post	0.010*	2.276	1.216	4.260
Both
MDS other branch
How often do you use rubber dam for endodontic treatments?
Always	<0.001*	0.256	0.116	0.565
Occasional	<0.0001**	0.347	0.211	0.570
Don’t use
Preferred technique of instrumentation for root canal treatment
Hand instruments	0.133	2.140	0.793	5.775
Rotary	0.013*	2.223	1.187	4.166
Combination
Obturation technique that you prefer?
Lateral	<0.0001**	3.053	1.748	5.332
Vertical	0.253	2.166	0.575	8.158
Core carrier	0.993	53,313,194.303	0.000	.c
Single cone
When do you prescribe the drug regimen (analgesics, anti-inflammatory, antibiotic)
Pre	0.100	1.592	0.915	2.768
Post	0.008*	2.063	1.207	3.526
Both

CI: Confidence interval, MDS: Masters of dental surgery, PG: Postgraduate

DISCUSSION

This study was conducted with the aim of comparing the practices of various dental practitioners belonging to different parts of India toward RCT. The rationale behind choosing these groups, i.e., MDS in endodontia, MDS in another branch, postgraduate students in endodontics, and postgraduate students of other branch was beneficial as all the participants manifest an exposure toward Masters in Dentistry curriculum and have been vividly trained with the basis of performing a successful RCT.

Demographics

In the present study, it was found that 60.8% of the participants were females which were similar to a study conducted by Mohan et al. Contrasting findings were reported by Slaus and Bottenberg (37.5%)[7] and Kohli et al. (45.1%).[6] In the present study, 57.3% of the participants were private practitioners and only 10% of them were both academicians and clinicians which was similar to a study conducted by Kohli et al.[6] where he reported that 64.2% of the participants were private practitioners. This could be attributed to the lack of academic job opportunities after postgraduation.[8] The other branch postgraduates included dentists enrolled for the MDS pedodontia (34.35%) curriculum as they were also trained for endodontic practices during their course duration.

The present study reported that 49.5% of the participants had experience below 1 year which was similar to a study conducted by Unal et al.[9] where he reported that 36.4% of the participants had below 1-year experience. Contrasting findings were reported by Slaus and Bottenberg (13.5%)[7] and Kohli et al. (10.1%).[6] The present study included professionals practicing both fresh and re-treatment cases of RCT (62.77%) which was in accordance with studies conducted by Kohli et al. (64.2%).[6]

Endodontic practices

Rubber dam

The present study reported 47.5% of Indian practitioners never used a rubber dam. It was seen that 50.80% of the endodontists used rubber dam occasionally as compared to 26.7% of the PG students of the endodontists. Multiple reasons for the inadequate use of rubber dams were reported in earlier studies.[10] These included patient discomfort, insufficient time, difficulty in use, insufficient training, cost, and low fees for treatment. Copious studies conducted by Tanalp et al. at America (59% of general dentists and 92% of endodontists),[11] Whitworth et al.[10] (only one-fifth of dentists in the UK), Sisir et al.[12] at New Zealand (57% of general dental practitioners) communicated the use of rubber dam for routine endodontic treatment which was contrasting to the present study findings. There are reports from studies conducted by various authors including Kaptan et al. in Turkey[13] and Al-Omari in North Jordan[14] where they inferred that dentists fail to comply with international standards and avoid using rubber dam. The reason could be attributed to derisory education in the undergraduate curriculum, increased time involved, expensive, and dentist discernment toward patients abhoring it. In the present study, 64.7% of the postgraduate students did not use rubber dams as compared to the other branch postgraduates (54.9%). The pedodontists used rubber dam more frequently than the endodontists as the chances of instrument aspiration are more in pedo patients as compared to middle-aged ones.[15] The trend was similar among MDS in other branch (33.92%) dentists. This could be because they were handing different age groups of patients and are exposed to varied clinical procedures which might require mandatory rubber dam usage. The findings of the study were similar to a study conducted by Lunch and McConnell.[6] Practitioners may equate rubber dam use with time loss, patient pain, extra cost, frustration, and irritation (Christensen 1994).

Preferred method of instrumentation

The present study reported that most of the postgraduate students of other branches preferred hand instruments for instrumentation and the least preferred by the endodontists which was similar to the study conducted by Slaus et al.[7] The preference toward hand instrument over rotary instruments was reported by the students due to the lack of experience with rotary instruments.[1617] Most of the endodontic students were seen to prefer combined method of instrumentation because they were trained appropriately with the improved properties and effective performances of the rotary instruments.[18] In the present study, the postgraduate students preferred the combined method of instrumentation (54.28%) as compared to a single method which was similar to the study conducted by Kohli et al. where he reported that the postgraduates chose rotary instruments over other instruments. A study conducted by Jenkis et al. (2001) in the UK stated that all dental practitioners were inclined toward the use of rotary instruments. This is attributed to time management and attending more number of patients daily.

Preferred method of obturation

The findings of this study showed that a single cone technique was the most preferred obturation technique among endodontists in India which was in contrast to a study conducted by Kohli et al. (2002),[6] Jenkin et al. (55%), Whitworth et al.[10] (59%), and Kohli et al. who found cold lateral condensation to be the most common technique of obturation. However, Slaus et al.[7] in his study reported that the continuous-wave technique was preferred over lateral condensation as the obturation technique for the American Board of Endodontics diplomats who participated the survey. In the study by Kaptan et al.,[13] gutta-percha with sealer without lateral condensation was favored the most (55.3%), followed by cold lateral compaction (33.8%). Core carrier was absolutely not used by the endodontists, while only 6.72% of the postgraduate students belonging to other branches.

Drug regimen

The present study reported that 30.85% of the postgraduate students of endodontics prescribed pretreatment medication as compared to 62.40% of the endodontists who preferred medication for both. In a study conducted by Slaus and Bottenberg,[7] 20% of the respondents only prescribed antibiotics and analgesics, while other respondents performed a pulpectomy in connection with analgesics and antibiotics. No significant difference for microbial efficacies in single visit or multiple visit RCT has been observed; hence, the use of systemic antibiotics posttreatment was not mandatory and that proper mechanical preparation and cleaning would eliminate or reduce the use of systemic drug usage.[19]

Strength and limitation

The study was methodically carried out taking the entire nation into consideration. It is the first kind of nationwide study where comparisons have been made among the various levels of dental practitioners. The study may have been subjected to reporting bias. A better study design would include an exploratory component on the root canal practice which would help in exactly identifying the reasons behind the individual practice.

CONCLUSION

The present study surveyed and collated the status of endodontic practice among postgraduates pursuing MDS in endodontics, postgraduate students pursuing MDS in other branches, Indian endodontists, and MDS other branches. It showed a varied profile of the dentists with most of them following the basic protocols and techniques of international standards. There are still certain differences among the various dental practitioners that recommend for the standardization of treatment guidelines for the dental practitioners of India. The study is unique in comparing the various different levels of dental practitioners and reporting their practices. These findings would reach a consensus to set an Indian endodontic treatment protocol/guideline by the Indian Board of Endodontists similar to one done by the European Society of Endodontists, American Association of Endodontists, and the Canadian Academy of Endodontists.

Financial support and sponsorship

This is a self-funded project.

Conflicts of interest

There are no conflicts of interest.