|Year : 2014 | Volume
| Issue : 6 | Page : 729-736
|A comparative evaluation of endodontic practice trends in India: "The Mumbai study"
Anil Kohli1, Shishir Singh2, Rajesh Podar2, Shifali Dadu2, Gaurav Kulkarni2
1 President Indian Endodontic Society; Consultant, Armed Forces Medical Services; Chairman, Commission of Dental Education (APDF); Adjunct Professor Boston and Tufts University, USA; Fellow American College of Dentists, USA
2 Department of Conservative Dentistry and Endodontics, Terna Dental College, Maharashtra University of Health Sciences, Nerul, Navi Mumbai, Maharashtra, India
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|Date of Submission||06-Nov-2014|
|Date of Decision||01-Dec-2014|
|Date of Acceptance||01-Jan-2015|
|Date of Web Publication||02-Mar-2015|
| Abstract|| |
Introduction: Multiple treatment protocols are available to the Indian endodontist. Hence a survey is required to recognize the common trends in endodontics and set a basic standard of treatment.
Aims and Objectives: The aim of this article is to present practice trends among Indian endodontists and compare the same with established practice trends internationally through various surveys that have been conducted respectively. Materials and Methods: Questionnaires were mailed to 1085 endodontists in dental schools and private practice in India. A response rate of 42% was observed. The data was analyzed and compared with other studies.
Results: Most of the endodontists in India follow the basic protocols and techniques in their practices. 40% of the Endodontists preferred digital radiography technique. 2.5% NaOCl is the most preferred irrigant of choice for primary root canal treatment and 2% chlorhexidine in retreatment cases. Calcium hydroxide was the most preferred intracanal medicament in all clinical situations. Lateral compaction (70.8%) was the most widely used method. AH Plus was the most preferred root canal sealer (46.6%).
Conclusion: Indian endodontists are following the basic protocol but when compared to other studies there were concepts like, the use of rubber dam and microscope which need to be improved and raised to a level that ensures international standards in clinical practice.
Keywords: Endodontists, Questionnaire survey, Comparative evaluation of survey, root canal treatment, India
|How to cite this article:|
Kohli A, Singh S, Podar R, Dadu S, Kulkarni G. A comparative evaluation of endodontic practice trends in India: "The Mumbai study". Indian J Dent Res 2014;25:729-36
The field of endodontics is expanding at a rapid pace with the entry of many new materials and technological advances. This often leads to a myriad of choices and treatment options for the endodontist. A survey of common practices amongst endodontists throws light on the usual methods adopted, either correctly or incorrectly. A few such surveys have been conducted in the past, notably in Western literature. In 1977, one such survey was conducted to determine trends in the treatment of endodontic emergencies based on questionnaires answered by Diplomates of the American Board of Endodontics.  A second such survey conducted in 1990 compared treatment modalities being rendered in endodontic practices.  With an ever expanding cohort of endodontists in India, a survey from an Indian perspective is needed to gauge the commonly selected practices. It is also important to compare these choices to global practices. Hence, a study was designed to bridge these lacunae. We hope that this would help formulate standardized Indian guidelines and improve patient care. This study would not only help in monitoring endodontic diseases trends but also evaluate and assess endodontic treatment protocols in India.
|How to cite this URL:|
Kohli A, Singh S, Podar R, Dadu S, Kulkarni G. A comparative evaluation of endodontic practice trends in India: "The Mumbai study". Indian J Dent Res [serial online] 2014 [cited 2019 Oct 17];25:729-36. Available from: http://www.ijdr.in/text.asp?2014/25/6/729/152179
The aim of the study is to investigate and compare the status of endodontic practice among Indian endodontists that will help suggest a standardized treatment guideline.
| Materials and methods|| |
One thousand and eighty-five endodontists were randomly selected amongst dental colleges and private dental practitioners. A questionnaire was posted to them accompanied by an explanatory cover letter. A self-addressed postal return envelope was also sent for a quick response. Prior ethical approval was taken from the Ethics Committee. The survey consisted of questions concerning different aspects of endodontic treatment including personal and demographic details, use of radiographic techniques, analgesic and antibiotic prescriptions, rubber dam, local anesthesia, technique of root canal instrumentation, techniques for working length determination, choice of irrigants with needle choices, choice of intracanal medicaments, use of ultrasonics, obturation techniques, choice of material for sealer, temporary filling, permanent filling and perforation repair, and methods for magnification. Help was also taken from a prior pilot questionnaire developed and analyzed at the Department of Endodontics at Terna Dental College, Nerul, Navi Mumbai after due clearance from Ethical Committee (Ethical clearance no. Approval no. TDC-EC/03/2011). The data were tabulated and analyzed using Statistical Program for the Social Sciences software (version 16.0) (SPSS Inc, Chicago, IL, USA). Chi-square test was applied to study the association between gender, year of postgraduation with type of practice, rubber dam, radiographic technique and technique of instrumentation.
| Results|| |
The data collected are compared to the results of other studies conducted in various countries given below in [Table 1] to know the standard of endodontic practice in India when compared to the other developed and developing countries.
Of the 1085 questionnaires distributed, 455 completed replies were received with a 42% response rate. The results are presented from [Table 2] [Table 3] [Table 4] [Table 5] [Table 6] [Table 7] [Table 8] [Table 9] [Table 10] [Table 11] [Table 12] [Table 13] [Table 14] [Table 15] [Table 16] [Table 17] [Table 18] [Table 19] below. The professional and demographic data shows the distribution of the respondents according to age, sex, year of practice and professional experience [Table 2]. Majority of respondents were in the age group between 31 and 40 years. Maximum participant in the survey was graduates after 2000. About 40.7% were having practice for 2-5 years, 64.2% of the participants were both in practice and academics. 40% of the endodontist preferred digital radiography technique and 26.8% used a combination of both digital and conventional technique. Amoxicillin (48.1%) and ibuprofen with paracetamol (34.3%) combination were the most preferred antibiotic and analgesic used. It was found that 50.5% of the endodontists were using rubber dam. About 99.1% preferred local anesthesia during access opening. The combination technique of root canal preparation and instrumentation with protaper were the most widely employed by Indian endodontists. Multiple modalities for working length determination were found to be generally used across the survey participants. In different clinical situations, the respondents showed the uniformity in remaining short of the apex. About 2.5% NaOCl was found to be the most preferred irrigant of choice for primary root canal treatment whereas 2% chlorhexidine was the most preferred choice in retreatment cases. The preferred needle type for irrigation by all the respondents for all clinical situations was beveled. Calcium hydroxide was the most preferred intra-canal medicament in all clinical situations. Only 4.6% of the respondents used magnification >75% of the time. Use of ultrasonics was found to be highest for removal of posts (55.6%) followed (38.9%). Lateral compaction (70.8%) was the most widely used method followed by single cone technique (19.6%). AH Plus was the most preferred root canal sealer (46.6%) followed by zinc oxide eugenol (32.1%) and endomethasone (14.3%). Amongst all temporary cements zinc oxide eugenol (40.2%) was the most preferred. Composite (81.5%) was the choice of material by most of the respondents. Mineral trioxide aggregate (MTA) was the material of choice in cases of perforations coronal to crestal bone (54.9%), apical to the crestal bone (87.9%) and for root end filling (81.5%).
|Table 4: Response details for preferred Analgesics, Anti‑inflammatories and Antibiotics|
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|Table 5: Response details to use of rubber dam and administration of local anesthetic in various situations|
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|Table 6: Response details to method and technique of root canal instrumentation|
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|Table 7: Response to preferred technique for working length determination|
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|Table 8: Response to preferred level of instrumentation in different clinical situations using the radiographic technique and the electronic apex locator|
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|Table 9: Response to preferred irrigation regimen in primary root canal treatment and retreatment in open and closed apices cases|
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|Table 10: Response to preferred needle types for irrigation in primary root canal treatment and retreatment in open and closed apices cases|
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|Table 11: Response to preferred medicament in various clinical situations|
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|Table 17: Response to preferred post endodontic permanent restorative material in anterior and posterior teeth|
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|Table 18: Response to preferred material for treating perforation defects and root end fillings|
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|Table 19: Association between gender, year of post graduation with type of practice, rubber dam, radiographic technique and technique of instrumentation|
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| Discussion|| |
It was interesting to note that none of the surveys on practice trends have studied all the steps in endodontic treatment as exhaustively as has been done in the present study [Table 1]a and 1b]. In the present survey, most of the endodontists preferred digital radiographic technique or a combination of digital and conventional. Similar results are shown in a study by Lee et al.  where 70% of dentists were using digital radiography compared to much smaller percentage still using conventional radiographic technique.
Preferred drug of choice among Indian endodontists was amoxicillin. When compared to other studies by Whitten et al.,  Lee et al.,  penicillin was reported to be the most commonly prescribed antibiotic while amoxicillin was the second choice. Amongst the analgesics, most Indian endodontists preferred prescribing a combination therapy of analgesics ibuprofen + paracetamol, probably because it is the most popular and readily available over-the-counter analgesic presently. Compared to this, the studies by Whitten et al.,  Lee et al.  showed ibuprofen was the most frequently prescribed analgesic among American dentists.
In the present study, 50.5% of Indian endodontists used the rubber dam, which was very striking. When compared to other studies by Whitten et al. (59% of general dentists and 92% of endodontists in America),  Whitworth et al.  (only 1/5 th of dentists in UK), Koshy et al.  (57% of general dental practitioners in New Zealand) reported using rubber dam routinely in endodontic treatment. Some studies like that of Kaptan et al. in Turkey  and Al-Omari in North Jordan  showed that dentists do not comply with international standards and do not use rubber dam. The reason for this could be inadequate education in the undergraduate curriculum, additional time involved, extra cost and dentist perception that patients dislike it.
The present survey showed that most of the endodontists prefer local anesthesia mainly during access opening, with the percentage going down for cleaning and shaping and obturation. This could be attributed to the inherent fear of the patient for needle prick. A study by Bangerter et al.  showed that most dentists use some form of supplemental intra-osseous anesthesia. Postgraduates after 2000 preferred rotary instruments compared to those graduated before 2000. In contrast, survey by Al-Omari has shown more use of hand instruments.  Lee et al.  also reported the maximum use of hand files in his study.
In present study, majority of participants preferred to use a combination of radiographs and apex locator for working length determination. This reflects the increasing use of technological advances in our country. Contrasting results were shown by Lee et al.  and Jenkins et al.  in UK where majority of the respondents took radiographs only. With use of either electronic apex locator or radiographs, the respondents preferred to be short of the apex, while Lee et al. in their survey showed that 30-40% of respondents instrumented to the level of apex reading on the electronic apex locator regardless of the clinical situation.
In the present survey, it was observed that the choice of irrigants was mainly 2.5% sodium hypochlorite that is in agreement by Dutner et al.,  Clarkson et al.  in Australia, Whitten et al.  In the present survey, the beveled tip needle was preferred, which was in agreement with Kaptan et al.  and Gopikrishna et al.  In the present survey, calcium hydroxide was the preferred medicament as found by Whitten et al.,  Lee et al.  and Jenkin et al.  In contrast, in a study by Al-Omari  in North Jordan, it was found that the most common material used was tricresol formalin followed by Ca(OH) 2 . The use of magnification in India was found to be less in contrast to Mine et al.,  Kersten et al.  and Lee et al.  and which is probably because of less training of the operator on the microscope. When compared with the study by Lee et al.  and Dutner et al.  it was found that the usage of ultrasonic is more in America probably due to cost effectiveness.
Cold lateral compaction technique has been the most popular root filling technique. However, in the study of Lee et al.,  continuous wave technique has now surpassed lateral condensation as the obturation technique for the American Board of Endodontics diplomats who responded to the survey. In studies by Jenkin et al. (55%)  and Whitten et al.  (59%), cold lateral compaction was the technique of choice. In the study by Kaptan et al.,  gutta percha with sealer without lateral condensation was favored the most (55.3%) followed by cold lateral compaction (33.8%). This shows that endodontists in India are not strong advocates of the more recently introduced advanced obturation techniques. This may be attributed to additional cost involved or the lack of skill and training.
The most popular sealer among Indian endodontists [Table 15] was AH Plus (46.4%). This finding is in accordance with the findings of Kaptan et al.,  but in contrast with the findings of Jenkins et al.,  Ahmed et al. and Al-Omari  who found that the majority of the respondents used zinc oxide based sealers. Zinc oxide eugenol cement was the most preferred for temporary sealing the access cavity among Indian endodontists. Lee et al.  in their study found that ⅔ of the respondents were using cavit. These materials have been marketed for over 50 years and have not been replaced by any new restorative materials for the purpose of sealing access preparation on a temporary basis.
Choice of permanent restorative material among Indian endodontists for both anterior (81.5%) and posterior (50.3%) teeth was mainly composite. Similar use of composite as the permanent restorative material was reported in the survey by Kaptan et al.  in Turkey. Whitten et al.  reported use of composite as the anterior restorative material while amalgam was slightly preferred over composite for posteriors. MTA was found to be widely used to repair perforation defects at all level in the present study. Similar finding was reported by Lee M et al.  where MTA was the most popular material for both perforation repair and root end fillings. This showed that the research results have translated to increased clinical use of the material.
Also, the present study [Table 19] showed that females are mainly into academics whereas males are both into academics and private practice. The recent graduates are into academics and use rubber dam in the practice as compared to those who graduated before year 2000. Males prefer rotaries while females prefer combination of rotary and hand instrumentation.
| Conclusions|| |
This study investigated and compared the status of endodontic practice among Indian endodontists. It showed that dentists are following the basic protocols and techniques in accordance with recognized international standards. But still there are certain differences that suggest a need for standardization of treatment guidelines for the Indian specialist. These findings would help reach a consensus to set an Indian endodontic treatment protocol/guideline by the Indian Board of Endodontists similar to one done by European Society of Endodontists, American Association of Endodontists and the Canadian Academy of Endodontists.
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Department of Conservative Dentistry and Endodontics, Terna Dental College, Maharashtra University of Health Sciences, Nerul, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19]
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