Radiographic Quality of Root Canal Treatments

radiographic Quality of origin Canal Treatments title of respect radiographic fiber of solvent render discourses performed by undergrad alveolar consonant studentsAuthors Masoud Saatchi1, Golshan Mohammadi2, Armita Vali Sichani3 brandal Research Center, De cleavement of endodontics, School of odontology, Isfahan University of health check Sciences. Isfahan, Iran.School of Dentistry, Isfahan University of Medical Sciences. Isfahan, Iran.Department of Endodontics, School of Dentistry, Isfahan University of Medical Sciences. Isfahan, Iran.SummaryThe aim of the present cultivation was to evaluate the musical note of radix render treatments performed by students of Isfahan University School of Dentistry in the midst of 2013 and 2015. Periapical radiographs from 784 composition hard-boiled odontiasis including 1674 infrastructure canals were randomly selected and evaluated in terms of woodland of rout fills ( continuance and parsimoniousness of bloodline pickaxes) a nd adjective errors (ledge, reprieve perfo dimensionn, starting time perfo dimensionn, and fractured instrument). Descriptive statistics and chi hearty test were used for evaluation of the data (PKey words dentistry, procedural errors, radiography, reservoir canal treatment, undergraduate studentIntroductionRoot canal treatment (RCT) is an important part of comprehensive alveolar c ar (1). High prevalence of apical periodontitis in endodontically treated teething, as report by epidemiological studies (2-4), reveals that aftermath of RCT in mevery populations is poor, which as a health c be fuss can elicit medical, economical and ethical consequences (1).Outcome of primary endodontic treatment is reported to be associated with many accompanimentors (5). One of these factors is technical quality of RCT that is usually evaluated victimization radiographic manner (3, 6). Its signaln that the length of the subside filling, coition to the radiographic prime, importantly affects the treatment forthcomes (7). In addition, stemma fillings with an adequate parsimony are strongly associated with a lower risk of periapical disease (8). likewise, procedural errors such as ledges, zip and elbow formations, fractured instruments and perforations whitethorn accrue during the RCT. These errors may result in compromised cleaning and shaping, leakage through reference filling or infection of the periradicular tissues and can jeopardize the endodontic outcomes (9).Recent studies all over in various population groups, show that undesirable quality is a common finding in RCTs performed by dentists and undergraduate alveolar consonant students (Table 1).thusly a worldwide enhancement in the quality of RCT is required (2) that could be achieved by means of education. Studies concerning quality of RCT are needed in revise to appraise the efficiency of dental training, highlight the weaknesses and help with the planning for dental education. Thus, the aim of th e present work was to evaluate quality of subject canal treatments (quality of root fillings and incidence of procedural errors) performed by students of Isfahan University School of Dentistry mingled with 2013 and 2015.Materials and methodsIn this cross-sectional report card, a random sample of 1200 plates were selected from the records of patients who had received RCT by undergraduate students at School of Dentistry, Isfahan University of Medical Sciences, Iran, during 2013-2015. Records with missing or ill-defined radiographs collect to improper imaging or processing technique, or those with radiographs that didnt show the entire length of the root canals and 2mm of periapical area, were excluded. Finally, 784 treated teeth including 1674 canals were evaluated.The RCTs were polished by fourth, fifth and sixth course of instruction undergraduate dental students according to the fallowing protocol after taking medical and dental history and diagnosis of palp and periapica l disease, topical anaesthetic anesthesia was injected and the access cavity was alert. An aseptic technique with rubber dekametre isolation was applied and working length was determined employ periapical radiographs. Canals were prepared using step back technique by means of chromium steel steel k-files of 0.02 taper (Dentsply, Tusla, USA or Mani, Tochigi, Japan). In some case Gates-Glidden drills (Mani, Tochigi, Japan) were used for preparation of lei third of the canals. Canals were irrigated by 2.5% sodium hypochlorite. Obturations were carried out using lateral compaction technique with gutta-percha cones (Ariadent, Tehran, Iran) and a ZOE comprise sealer. teeth were temporarily restored and referred for permanent restorations. For root canal treatment of apiece tooth, 4 periapical radiographs (preoperative, working length de expiration, master cone and postoperative) were taken by the bisecting-angle method using De Gotzen dental radiography machine (De Gotzen, Roma, I taly) and E speed coat 2 intraoral films (Primax, Berlin, Germany). Developing solutions (Champion, Tehran, Iran) were used to possess the radiographs in a time-temperature technique. Endodontist schoolman farce supervised all the treatment steps. Average academic stuff student ratio has been 1 6 at the time of the study.In launch to evaluate the quality of each RCT, at to the lowest degree 3 radiographs including preoperative, working length determination and postoperative, were examined. Evaluations were made in a dusky room under even illumination and 3x magnification. Radiographs were mounted in a cardboard slit to exclude the extraneous lights. Measurements were done using a transparent ruler of 0.5 mm accuracy. In cases that the radiographic images were taken with an alternation in horizontal angulation, it was supposed that they were exposed with a mesial angulation.Two one-on-one researchers (GM and AV) securitized the radiographs of each record. The results were com pared and in case of dis placement a third investigator (MS) was asked to examine the records, and a final harmony was achieved.Before the study, investigators were calibrated and Inter-examination agreement was determined by evaluating 30 radiographic records that werent included in the study. For establishing intra-examiner agreement, each investigator re-evaluated the same radiographs after 2 weeks.Evaluation of quality of RCTs was accomplished by examining radiographic quality of root fillings and spotting of the procedural errors. Root canal was considered as the unit of evaluation.Quality of root filling in each canal was categorized as acceptable and impossible based on the following criteriaAcceptable root filling root filling ending 0-2 mm from radiographic apex without any visible voids in the filling plug or between the filling mass and root canal walls.Unacceptable root fillingOverfilling root filling that extends beyond radiographic apex.Undrefilling root filling en ding shorter than 2 mm from the radiographic apex.Inadequate density root fillings with visible voids in the filling mass or between the filling mass and root canal walls.The criteria for the sleuthing of procedural errors in this study, were as followsA ledge was identified if the root filling in the final radiograph did not follow the bend of the main canal path in working-length radiograph.Root perforations (including furcation perforation, peeler perforation and lateral perforations of the root) were spy when extrusion of the filling bodilys was identified in any area of the root except the apical foramen.Foramen perforation was diagnosed when the apical termination of the filled canal appeared as an elliptical shape transported to the outer wall.Fractured instruments was detected by observing a part of instrument in the root canal or in periarticular area in the final radiograph.statistical analysisData were analyzed using SPSS software version 21 (SPSS Inc., Chicago, USA) . Descriptive analyzes were used for expressing frequency of radiographic criteria of quality of RCTs. Pearsons chi square test was used to compare the results among tooth types and locations and also academic class of students. P-values ResultsFrom 1200 salt away records of endodontically treated teeth, 416 cases (34.7%) were excluded and 734 teeth including 1674 root canals were evaluated. 52% of treated root canals were in maxilla and 48% were in mandible. Canals of grinder teeth comprised the most usual treated root canals (68%), followed by canals of premolars (22%) and anterior teeth (10%) . sixth course of study students performed RCTs on 49% of root canals. 5th and 4th year students treated 32% and 19% of root canals, respectively. Anterior teeth and premolars constituted the teeth treated by 4th year students while 5th and 6th year students treated premolars and molars (Table 2).Technical quality of root fillingsAccording to length and density, acceptable fillings was found in 54.1% of root canals. From treated maxillary root canals, 56.2% and from treated mandibular root canals, 51.9% were acceptable. Rate of acceptable root fillings wasnt significantly assorted between the both arches (P=0.072). Among tooth types, canals of molar teeth exhibited lower ratio of acceptable root fillings (51.3%) compared to premolars (61.3%) (P=0.001). Rate of acceptable fillings in anterior teeth (57.7%) wasnt significantly unlike from molars (P=0.430) and premolars (P=0.128). Inadequate density, overfilling and underfilling was found in 34.6%, 11% and 8.3% of root canals, respectively. In both arches inadequate density consisted the most common pillow slip for unacceptable fillings. In maxilla overfilling consisted the second frequent cause for unacceptable fillings, followed by under filling, However, underfilling was the second common cause of unacceptable fillings in mandible and overfilling was the least frequent cause (Table 3).From the root canals trea ted by 5th year students 46.1% had acceptable fillings which is significantly lower than canals treated by 4th year students (55.6%) (P=0.007) and 6th year students (58.8%) (Pth and 6th year students (P=0.339) (Table 4). adjectival errorsProcedural errors were found in 18.6% of root treated canals. Incidence of procedural errors between 5th year students (22.2%) and 6th year students (19%) wasnt significantly disparate (P=0.149). Students of 4th year had created less procedural errors (11.6%) than students of 5th year (Pth year (P=0.003).Ledge was the most frequent procedural error and was identified in 12.5% of root treated canals. Foramen perforation, root perforation and fractured instrument were detected in 2%, 2.4% and 2% of canals, respectively (Table 5).Incidence of procedural errors wasnt significantly different in canals of anterior teeth (12.3%) and premolars (9.5%) (P=0.341). These errors were significantly more frequent in canals of molars (22.5%) than anterior teeth ( P=0.003) and premolars (PThe k-value for inter-examiner agreement was 0.87 for staining of acceptable root fillings and 0.81 for designation of RCTs without procedural errors. For intra-examiner agreement k-values for detection of acceptable root fillings and identification of RCTs without procedural errors were 0.93 and 0.87 for first and 0.84 and 0.81 for second investigator, respectively.DiscussionThis study was designed to evaluate the quality of root canal treatments accomplished by undergraduate dental students at School of Dentistry, Isfahan University of Medical Sciences. Periapical radiographs taken during the RCT procedures were used for this investigation. Root fillings were considered acceptable if complete 0-2 mm from radiographic apex and had no voids. This criteria is extensively documented to be associated with improved periapical health (4, 5, 8).In order to limit inter-examiner and intra-examiner erraticism, the radiographic criteria were stringently defined and two investigators were calibrated before the study. Its reported that great variations could experience between investigators regarding assessment of technical quality of RCT (22). In the present study, the k-value of 0.87 for detection of acceptable root fillings and 0.81 for identification of RCTs without procedural errors, exhibit good agreement between the investigators. Also values for intra-examiner agreement were found to be greater than 0.81, which shows reliability of each investigator.Acceptable root fillings according to length and density was found in 54.1% of investigated canals. Comparing this result to the findings of others is rather difficult due to differences in level of practitioners (undergraduate students, commonplace practitioners, and endodontists), techniques and substantials used for preparation and obturation of the canal and also evaluation criteria used to assess the quality of RCT. For example, in the study of Bierenkrant et al. (18) who investigate d root canals treated by endodontists, 91% of root fillings had adequate quality which is greater than the present study and other studies investigating quality of RCT performed by undergraduate students and general practitioners (Table 2). Among the studies concerning quality of RCT performed by undergraduate students, frequency of acceptable fillings in the current study is comparable to the findings of Eleftheriadis Lambrianidis (14) (55.3%) and Khabbaz et al. (19) (54.8%). In the study of Er et al. (15), 33% of root fillings were acceptable which is less than the present study thought, they used different evaluation criteria. Lynch and Burke (16) reported adequate fillings in 63% of RCTs, which is higher than the present study, however they only evaluated single rooted teeth.In the present study, inadequate density was the most common cause for unqualified root fillings. This is consistent with the findings of Balto et al. (20). Its believed that lateral condensation technique with gutta percha, could create voids in canals with insufficient flaring (14).No significant difference was found between quality of maxillary and mandibular root fillings. Also adequate root fillings in molars were less than premolars. This result was consistent with findings of Er et al. (15) and Khabbaz et al. (19) who report a lower quality of root fillings in molar teeth. This could be explained by posterior position and complex anatomy of these teeth.Students of 5th year had performed more unacceptable root fillings than 4th and 6th year students. This could be explained considering the fact that at Isfahan University School of Dentistry, first clinical encounter of undergraduate students with molar teeth, is at their 5th year of study.Iatrogenic errors were detected in 18.6% of root canals. These errors are more frequent in molar teeth. Balto et al. (20) and Khabbaz et al. (19) also reported a high prevalence procedural errors in molar teeth. The reason out for this, could be explained by curved and narrow canals of molar teeth, which makes them challenging for undergraduate students. Furthermore, 5th and 6th year students had created more procedural errors than 4th year students. This is because 4th year students only perform RCTs on anterior teeth and premolars which are less challenging than molar teeth.In this study, ledge was found to be the most frequent procedural error and was detected in 12.5% of root canals. This finding is similar to incidence of ledged root canals in the study of Khabbaz et al. (19) and is less than study of Eleftheriadis Lambrianidis (14). Its shown that stainless steel hand files used by unexperienced undergraduate students could increase the incidence of ledge and other procedural errors (14).Radiographic images cannot illustrate all iatrogenic errors. For instance, over instrumentation which drives pulpal fragments and microorganisms beyond the apex into the periapical tissues, can only be radiographically diagnosed when it is followed by extrusion of filling material from the apex.The use of bisecting-angle technique for taking periapical radiographs, results in less accuracy in recognition of canal length, comparing to the parallel technique (23). It has also been shown that using only one orthoradial radiographic image for assessing the adaptation of the filling material to the root canal walls, isnt reliable. This adaptation has to be further investigated with at least one extra radiography of distal or mesial angulation in order to obtain more realistic estimate of density of root filling (24).Although radiographic quality of RCT is a significant determinant in predicting outcomes of primary endodontic treatment, the radiographic images can not reflect the general quality of treatment. Application of the antiseptic and aseptic techniques, material used and microbial circumstance of the canal are the predicting factors which are not investigated in radiographic studies.At Isfahan Universit y School of Dentistry, Step-back preparation and cold lateral condensation techniques are being taught to the undergraduate dental student. Most universities teach these standard techniques to their students. Its shown that using rotary Ni-Ti instruments provide better canal shaping, reduce the procedural errors and are being taught in undergraduate curriculum in some dental schools (17).In many studied insufficient time allocated to clinical and presymptomatic training, the academic stuff student ratio and evaluation methods are utter as reasons for low quality of RCTs in university clinics (14, 19, 20). Isfahan University School of Dentistry uses endodontic specialists and 3rd year post graduate students as training stuff. Also academic curriculum have been recently revised to increase presymptomatic training. Nevertheless, enhancing the time allocated to clinical training and increasing stuff student ratio could lead to improvements in quality of RCTs performed by undergraduate students.In conclusion, findings of this study shows that 54.1% of root fillings performed by undergraduate students of Isfahan University School of Dentistry were acceptable. Thus, there a necessity to revise the educational programs in Endodontics in order to improve quality of root canal treatments.References1.Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J. 200235(3)229-38.2.Asgary S, Shadman B, Ghalamkarpour Z, Shahravan A, Ghoddusi J, Bagherpour A, et al. Periapical Status and Quality of Root canal Fillings and Coronal Restorations in Iranian Population. 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