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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 10  »  A survey of endodontic practice amongst Flemish dentists
A survey of endodontic practice amongst Flemish dentists
Discussion - References.



Discussion.
This project sought to collect data from general dental practitioners in Flanders. Postal surveys provide a simple means of data collection, but they are often weakened by poor rates of return. In this survey, all Flemish dental practitioners were mailed. The response rate (25%) was poor but a second mail shot was impossible because the survey was anonymous. A similar survey held by the Council of the British Endodontic Society amongst GDPs in England also had a low response rate of 32% (Pitt Ford et al. 1983). Jenkins et al. (2001) obtained a response rate of 41% but limited their survey to practitioners graduated from one dental school.
Rubber dam isolation is considered the standard of care in endodontics. A survey amongst American GDPs indicated that 59% always used rubber dam (Whitten et al. 1996). In the UK, 60% (Whitworth et al. 2000) to 70% (Marshall & Page1990) reported not to use rubber dam for any procedure, whereas only 5% of the dentists working principally in the National Health Service (NHS) used rubber dam for endodontic treatment (Gergely 1989). Practitioners may equate rubber dam use with time loss, patient pain, extra cost, frustration and irritation (Christensen1994).Perhaps the low use of rubberdam( 3.4%) of our respondents was one of the reasons why only 34%of the GDPs enjoyed endodontic treatment (Table 6).
In the USA, a definite trend towards single-appointment treatment is evident. Gatewood et al. (1990) in a survey of 568 actively practising diplomats of the American Board of Endodontics reported that 34.7% would complete cases in one visit for teeth with a normal periapex and only 16.2% would do so if apical periodontitis were present. Whitten et al. (1996) found that endodontists preferred single-visit therapy, whereas GDPs preferred multiple visits. In both cases, the percentage dropped for patients presenting with pain. Most of the GDPs of the present survey reported little difference in the number of appointments when completing an endodontic treatment in a tooth with one or four root canals. As many endodontic treatments in general practice occur owing to pulp exposure or acute pain, one session may be spent with an (emergency) pulpotomy with preparation and obturation scheduled for a following appointment. This may explain why there is little difference in the number of sessions between teeth with single and multiple root canals (Table 2c).
Owing to the variability of the point of exit of the root canal in the apical region (Kuttler 1955) determination of the working length has always been a challenge (Gatewood et al.1990). In the study of Sjogren et al. (1990), it was stated that in cases where the pulp was necrotic and infected, the working length should be chosen within 1mm of the radiographic apex. The optimal working length in teeth with vital pulpappears to be1-2 mm from the radiographic apex (Kerekes & Tronstad 1979). In our survey, 38.9% of the GDPs used instrumentation levels1mmshort of the radiographic apex, independent of the pathology. Whitten et al. (1996) reported that 75% of the respondents stated that they would instrument 0.5 mm short of the radiographic apex. Another reason for the choice of working length of the present group of practitioners was the rule of the Belgian health insurance authority stating that root canals ‘‘must be filled minimally up to1 mm short of the radiographically visible end of the root canal’’, which must be substantiated by a radiograph which the patient has to furnish to the insurance company prior to reimbursement.
A second root canal in the mesiobuccal root of the first maxillary molar which is not prepared and filled can be the reason for treatment failure. In our survey, more then 70% of the respondents never or seldom prepared and  filled a fourth root canal in a maxillary molar, whilst Kulild & Peters (1990) indicated that a second mesiobuccal canal was found in the coronal half of 95.2% of the mesiobuccal roots examined.
The traditional intracanal instruments such as reamers, K-files and Hedstrom file were the most widely used, mostly in combinations (Table 2d). More than 60% of the GDPs used a filing push-pull technique. The fact that 57.8% of the GDPs were satisfied with their preparation technique indicated they were conservative in their approach to shaping of root canals. However, 47% of the GDPs sometimes used nickel-titanium files, indicating that new developments were slowly being incorporated into daily practice.
Endodontic pathology associated with pain present a major part of dental emergencies. In a tooth with an acute pulpitis, the majority of the practitioners performed a pulpectomy, whilst some 20% only prescribed analgesics and antibiotics for patients with an acute apical periodontitis without any root-canal instrumentation. It may be the GDPs’ belief that this condition is associated with difficulty in obtaining a satisfactory level of anaesthesia was the reason they did not carry out any active treatment. In the survey of Gatewood et al. (1990), a majority of diplomats completely instrumented the canals regardless of the clinical diagnosis.
Pain after endodontic procedures is another reason for emergency treatment (Mor et al. 1992). Thirty-five percent of the Flemish GDPs reported complications after treating a tooth with chronic apical periodontitis. When looking at individual teeth ,molars were the teeth which presented most frequently with complications after endodontic treatment.
Sodium hypochlorite has proven to be a most effective antimicrobial agent (Bystrom&Sundqvist1983), an opinion that was shared by 59.2% of our respondents. In a study of Whitten et al. (1996), 79% of the GDPs used sodium hypochlorite as irrigant, whilst in the survey of Whitworth et al. (2000) in UK general dental practice, local anaesthetic solution was the most commonly used endodontic irrigant. Many clinicians prefer dilute concentrations to reduce the potential of sodiumhypochlorite to act as an irritant (Becker et al.1974). Twenty-eight percent of the Flemish GDPs used a concentration of 2%. Possibly, the limited use of rubber dam was a factor in the choice of more dilute solutions.
A high percentage (64.6%) of the GDPs used intracanal medicaments. Most practitioners used a cocktail of several products; but Rockle’s (Septodont, Paris, France, containing dexamethasone, phenol and formaldehyde) was one of the favourites (27.8%), althoughthereisno indication for their use according to present-day standards (ESE 1994). Gatewood et al. (1990) reported a decrease in the use of the more classical medicaments, especially camphorated monochlorophenol with exception to the use of formocresol when vital pulp tissue was present.
Over the years, numerous methods have been advocated to obturate the prepared root-canal system, each with their own claims of ease, efficiency or superiority. Most of the GDPs (61.6%) used lateral condensation as filling technique. In the recent survey of Qualtrough et al. (1999), cold lateral condensation remained the most popular undergraduate obturation technique.
According to ESE (1994) guidelines, sealers should be biocompatible. Pitt Ford et al. (1983) found that in England most private practitioners used non-medicated zinc oxide-eugenol root-canal cements whereas the majority of NHS practitioners used one particular medicated sealer, Endomethasone (Septodont, Paris, France). The most popular root-canal sealer amongst our GDPs was AH26 (29%). Although a group of approximately 15% used medicated sealers with 11% using an unspecified sealer.
Temporary restorative materials used in endodontics must provide a high quality seal of the access preparation to prevent microbial contamination of the root canal. Fifty-nine percent of the respondents use Cavit as temporary filling material, which under experimental conditions provided superior resistance to bacterial leakage (Beach et al.1996).
When evaluating the data of Table 6, the most striking finding is the generally negative attitude towards performing endodontic treatment. Only 34% admitted that they liked doing endodontics. This may be related to the public health-care system and specifically the low fee provided for root-canal treatment (one root canal: 32 USD; two canals: 43 USD; three canals: 65 USD; four or more canals: 86 USD; exclusive of radiographs and coronal restoration). Nevertheless, most practitioners were satisfied about their preparation and obturation technique.
The GDPs in the present enquiry preferred endodontic treatment for teeth presenting with a large periapical lesion. The most frequent answer was endodontic treatment alone (57%), which may be followed by or combined with apical surgery (16.8%); only 15.5% of the GDPs referred the case to an oral surgeon. This shows that dentists and patients prefer to retain teeth even in cases with a less-favourable diagnosis. This was equally true for teeth presenting with a substandard root-canal filling with a comparatively high percentage of practitioners (79.8%) performing endodontic re-treatments. Whitten et al. (1996) reported in their survey that only 25% of the GDPs performed re-treatments. A number of studies have revealed that much of the endodontic provision falls below international standards of care (Grieve & McAndrew 1993, Saunders et al. 1997). In a study of De Moor et al. (2000) in a Belgian subpopulation, 56.7% of the root- filled teeth were deemed inadequate. Another reason for this high score is the lack of specialized endodontists in Belgium as well as the low inclination of GDPs to refer patients.

References.

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