Student's confidence level in performing root canal treatment and its correlation with encountered errors

Introduction

A recent study reported that the overall frequency of acceptable technical quality of root fillings performed by undergraduate students, assessed radiographically, was low (48.75%) and decreased significantly as tooth position moved posteriorly.1 The most common errors reported in root canal treatment (RCT) performed by undergraduate students were ledges, furcation perforations, apical transportations and apical perforations.1 Endodontic treatment is considered one of the most technically difficult and stressful disciplines within the field of dentistry because of the anatomical diversity of the root canal system, which requires adequate knowledge from the operator.2

Endodontic treatments aim to preserve a tooth or to maintain part of the dental pulp healthy. When the dental pulp is infected or damaged, treatment aims to eliminate the infection and ensure the healing of the periradicular tissues.3 Generally in RCT, the damaged pulp is removed, cleaned and disinfected, and then filled three-dimensionally.

The incidence and demand of RCT in patients and awareness regarding saving their teeth as opposed to extraction are expected to increase further.4 Ideally, a dental officer should have acquired the necessary knowledge upon graduating so that they are able to diagnose endodontic cases correctly, develop a definitive treatment plan and carry out an adequate RCT.5, 6 Ng et al. in 20077 concluded in their study that the success rate of RCT lies between 68% to 85% where, during recall visits with a minimum of 6 months after treatment, there is complete resolution of periapical lesion. Clinically, successful endodontic treatment was described as the absence of symptoms (swelling, pain, tenderness to percussion and the sinus tract) and radiographically, as a reduction in the dimension of the periapical lesion or no change in size.8

One of the most important factors that influence productivity is confidence. Person, leadership, and team confidence are all important for success, and a lack of confidence has been linked to failure.9 The operators need to be confident that they should have ‘the feeling or belief that they have faith in their own abilities.10 It is essential to assess the operator’s level of confidence prior to treating a patient and work on enhancing their competency.

In general, there is limited information regarding the way students perceive endodontics and their level of self-confidence about various aspects of endodontic treatment with respect to their future practice.11 From the studies that we reviewed which have almost similar topics to our study10, 11, 12, 13, 14 about 60.0% of the study concluded that their students have a high level of confidence in performing root canal treatment, 20% displayed neutral and the other 20% showed low confidence level. However, all of the studies were conducted outside of Malaysia, which was in England, Sudan, Saudi Arabia and Yemen. To date, there is no similar study done in Malaysia that assesses the confidence level of RCT in undergraduate dental students. Therefore, the objectives of this study were to collect data from final-year undergraduate dental students regarding their confidence level in performing RCT and to investigate the correlation between the confidence level and problems encountered during the treatment.

Materials and Methods

Result

In this study out of 76 students, 84% were female and 16% were male with a mean age of 24-year-old. Figure 1 showed levels of students’ confidence in performing various endodontic procedures. Students displayed high confidence in performing endodontic treatments as the mean total confidence score of different endodontic procedures is 80%. The procedure in which students showed the highest level of confidence was the placement of a rubber dam isolation for which 93.4% of them scored as very confident, followed by administering local anesthesia and root canal irrigation (90.8%) (Figure 1). In performing endodontic procedures, only 1.3% reported a level of very little confidence in access cavities and management of interappointment flare-ups.

When rating the self-confidence for performing RCT of different teeth on the dental arch, maxillary anterior teeth (4.24±0.63) followed by mandibular premolars (4.11±0.72) are the teeth where the students felt the most confidence treating whereas they were less confident in treating maxillary molars (3.38±0.69).

Higher scores of self-confidence were reported in the management of different endodontic indications which include the management of necrotic pulp (4.22±0.65), followed by vital pulp treatments (3.95±0.61). According to the experience of RCT, the mean experience in preclinical anterior and posterior teeth are 2.61±1.10 and 2.46±1.14 respectively. While in clinical experiences they experience 2.01±1.38 in anterior teeth and 1.84±1.28 on posterior teeth which are slightly lower when compared to the preclinical experience.

Based on the questionnaire distributed, the highest mishap encountered during the clinical session by the students was canal blockage (Figure 2) which is 57.9%. The second most encountered error is the underestimation of length with a score of 52.6%. The percentage showed that more than half of the respondents have encountered these mishaps. In contrast, treating the wrong tooth and tissue emphysema was the least error encountered by the student with only 2.6%.

There was no significant correlation between confidence level in performing root canal procedures and mishaps encountered during RCT among final year dental students (p>0.05). The observed correlation coefficient was 0.13 which suggests a positive relationship and little or no correlation. The data were tabulated in Table 1.

Discussion

Numerous studies have been conducted to assess the quality and outcome of endodontic treatments performed by dental students; however, little is known about their level of confidence in different aspects of endodontic treatment in relation to their future practice. Therefore, this research was conducted to obtain information about the confidence of final-year undergraduate students at the Faculty of Dentistry, UiTM regarding endodontics management.

This study revealed that rubber dam placement scored the highest confidence among the students which coincides with other studies.12, 13, 14 There was some research, on the other hand, that found that students were less confident in the placement of rubber dams because the students only started working with rubber dams in their final year due to the unavailability of the rubber dam.10, 15 The second highest confidence level was administering local anesthesia where a similar result was found in other studies.12, 13

Access cavity preparation procedure scored the lowest confidence rate among the students in performing various endodontic procedures. Access cavity is difficult to perform as it requires precision and angulation. The operator must be familiar with the standard location of the pulp chamber in each tooth as the shape of a pulp chamber varies depending on the size of the tooth itself. Therefore, more attention is required to the theoretical and practical teaching of this subject. A study by Davey et al.12 found that students have a low level of confidence when performing endodontic access cavity preparation, which is similar to our results. Another procedure with low confidence levels among the students was the management of interappointment flare-ups. Flare-ups are a complex and poorly understood condition with a variety of etiological hypotheses.16 Mechanical, chemical, or microbial damage to the pulp or periradicular tissues, resulting in acute periradicular inflammation, is among the causes of this flare-up.16 Three studies found similar findings, describing low students’ confidence in flare-up management as a result of students' failure to communicate with patients to manage this complication.11, 12, 17 This occurs often because students lack experience and tactile skills, as well as those of an experienced dentist, to minimize or avoid over-instrumentation or extrusion of irrigants and intracanal debris into the periradicular tissues.10

The students felt most comfortable treating maxillary anterior teeth. This is due to their location which makes the teeth more accessible to be treated when compared to maxillary molars.13 Similar results were reported.11, 12, 17 While, maxillary molar teeth were found to be the most difficult teeth to treat which was consistent with the findings of other researchers.15, 17, 18 This is an anticipated outcome since molar endodontic treatment is a difficult procedure in which students have the least confidence.15 RCT of upper molars is complicated due to their location which makes the inability to see directly and complex anatomy such as the presence of mesio buccal two canal.17 As stated by Ng et al. in 2010,19 maxillary first molar teeth have the lowest survival rate because of failure to locate the mesiobuccal two canals.

Regarding the management of different endodontic indications, the students’ confidence was highest in managing necrotic pulp which is similar to a study conducted by Madfa and Senan.10 The students have high confidence in managing necrotic pulp because it is the most common clinical diagnosis in RCT patients. The second highest confidence score by the students was the management of vital pulp treatments which is similar to a study done by Tanalp et al. in 2013.17

The most encountered mishap during clinical sessions was canal blockage and underestimation of length. Canal blockage can be interpreted as blockage of the canal during the preparation phase by dentine or tissue debris in a previously patent canal that results in a shorter working length thus preventing access and complete disinfection of the desired working length of the tooth.20 It frequently occurs in canals prepared with a stepback technique with anti-curvature and circumferential filing.21 Another same study10 also reported that canal blockage was the main mishap occurring accompanied by ledge formation. While Tanalp et al.17 reported perforation as the most adverse occurrence students experienced in the clinic. Other reported22 frequent iatrogenic errors by senior dental students in RCT procedures include void and overfilling. Underestimation of working length was another common mishap encountered by the students which may cause incomplete instrumentation of the canal.

While for the least encountered error, we found that treating the wrong tooth and tissue emphysema have the same prevalence. Drying the root canal system with air under pressure using a three-way syringe might be the most probable contributing cause of tissue emphysema.23 Therefore, precautionary steps need to be taken to avoid the complication although the occurrence is rare.

The result of this study showed that there is no significant correlation between confidence levels in performing root canal procedures and mishaps encountered during RCT among final-year dental students which were similar to the finding by Awooda et al.11 Despite that, Awooda et al.11 also found that there is no association between overall confidence level and the number of performed RCTs as opposed to Murray and Chandler.6 Even though their clinical session was cut to almost 5 months during the pandemic period, the students still scored high in the confidence level. This might be due to the more practice of RCT on extracted teeth to complete the MCE and also the experience that they gained when assisting their partner in the clinics as four-handed dentistry is practiced.

Conclusion

In conclusion, our final-year undergraduates show high mean confidence of 80% in performing various root canal procedures. The self-evaluation of acquired skills and confidence levels by students is a useful tool for a realistic assessment of the dental curriculum, which will eventually help identify and overcome barriers. There was no correlation between the confidence level and problems encountered during RCT as each case treated is unique and different from each other where confidence level might also be affected by the experience of the operator.

Source of Funding

None.

Conflict of Interest

None.