Assessment of Knowledge, Attitude and Practice of C-shaped Root Canals among Dental Students and Dentists in the Makkah Region of Saudi Arabia- A Cross-sectional Study

1. Assistant Professor, Department of Conservative Dental Sciences, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia. 2. Interns, Department of Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia. 3. Interns, Department of Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia. 4. Interns, Department of Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia. 5. Interns, Department of Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Makkah, Saudi Arabia.

Abstract

Introduction: Thorough management of root canal anatomy and its variants is important for good prognosis of endodontic treatment. C-shaped root canal is one such important variation in root canal anatomy. Due to the complex nature of C-shaped root canals the clinicians should be familiar with this variation to achieve better success rate in endodontic treatment.

Aim: To assess Knowledge, Attitude and Practice (KAP) among dental students and dentists of the Makkah region of the Kingdom of Saudi Arabia towards C-shaped root canals.

Materials and Methods: A cross-sectional questionnaire survey was conducted for a period of five months from 25th September 2020 to 25th February 2021 in Dentistry program of Ibn Sina National College for Medical Studies, Jeddah using a self-structured, closeended, multiple-choice questionnaire consisting of 21 questions. The questionnaire was sent using online to 503 Dental students and Dentists of Makkah region of Saudi Arabia. The study population was selected using convenient random sampling. The questionnaire was constructed and validated with the help of five endodontists with adequate teaching and clinical experience. The data were analysed using IBM Statistical Package for the Social Sciences (SPSS) version 22.0 and descriptive statistics followed by Chi-square test was applied to test of variables in the questionnaire.

Results: In the study population, 68.4% (n=344) were males and 31.6% (n=159) were females, 25.2% (n=127) were undergraduate students and 74.7% (n=376) were graduate dentists, 63.2% (n=318) believe most commonly C-shaped root canals are found in mandibular second molars, 49.3% (n=248) have strongly agreed that they are proficient in diagnosing C-shaped root canals, 75.7% (n=381) have agreed that knowledge of canal anatomy will be helpful during access preparation of C-shaped root canals, 48.5% (n=244) felt use of crown down technique will be effective in managing C-shaped root canals,72.8% (n=366) felt multiple visit endodontics is needed for successful management of C-shaped root canals and 25.8% (n=130) felt use of thermoplasticised guttapercha compaction will be helpful in obturation.

Conclusion: Knowledge of anatomical variations of root canal system and the use of advanced endodontic instruments and techniques will enable the dentists to handle difficult root canal cases thoroughly for good prognosis of dentition.

Endodontic management, Mandibular second molar, Root canal anatomy

Complete knowledge and understanding of root canal system, as well as identification of atypical canal configuration are paramount for efficient root canal therapy (1). An important variation is the “C” configuration which was originally mentioned in the publication by Cooke and Cox in 1979 (2). It is termed based on the cross-sectional morphology of the root canal in the molar teeth. In variation to normal anatomy, the orifice of a C-shaped canal is ribbon-shaped and transcribes an arc of 180 degrees. The feature usually begins at mesiolingual line angle of the pulp chamber, curves buccally which terminates at the distal aspect (2). Failure of Hertwig’s epithelial root sheath to fuse on the lingual or buccal root surface is the most accepted as a cause of C-shaped root canals (3). Attaching a name to the atypical C-shaped canals led to various classification systems which was notably developed by Melton DC et al., and Fan B et al., (4),(5).

C-shaped canals often give a dentist an immense difficulty at the diagnostic level, during chemomechanical preparation and obturation. The incidence of C-shaped canal varies greatly among different ethnicities, common in Asians, but somewhat limited among European and Americans (6). C-shaped canals are usually observed in the mandibular second molar. However, it may also occur in maxillary molars, the mandibular first molar and mandibular first premolar (7),(8),(9). Although conventional radiography imaging remain the method of choice for endodontic management prior to endodontic treatment (10). CBCT is a valuable tool to evaluate the C-shaped root canal configuration in-vivo studies (11).

Knowledge and understanding of pulp chamber anatomy applied during access preparation like principle of colour change and principle of orifice location is very important to prevent endodontic mishaps. Due to the atypical form and complex nature of a C-shaped root canal, many methods are recommended to assist in the management of root canal treatment. Clinical case reports have suggested the use of ultrasonic instruments along with a nickel-titanium rotary system for successful cleaning and shaping (12) and application of thermoplasticised gutta-percha to achieve hermetic seal obturation (13). To reduce failure of endodontic treatment in C-shaped root canals, practitioners should have a thorough knowledge of root canal morphology, should provide complete debridement of root canals and hermetic seal in obturation (14).

Although, there is scientific literature about incidence, the morphology of C-shaped root canals and their significance in the success of endodontics (15). However, due to the complex nature of C-shaped root canals the clinicians will have difficulty in debridement and obturation of these types of root canals effectively. Till to date, to this knowledge no study has been conducted in the Makkah region of Saudi Arabia. Hence, the rationale behind the study was to ascertain KAP among dental students and dentists of the Makkah region of the Kingdom of Saudi Arabia towards C-shaped canals through a questionnaire-based survey.

Material and Methods

This research was a cross-sectional questionnaire-based study conducted in the Dentistry program of Ibn Sina National College for Medical Studies, Jeddah. The study was planned from 25^th September 2020 to 25^th February 2021 and completed in five months. Ethical clearance was obtained from the Institutional Ethical Committee with approval number (H-14-19102020).

Inclusion criteria: The undergraduate dental students of sixth year, interns, general dentists, specialist dentists were included in the study.

Exclusion criteria: The undergraduate dental students of fourth year, fifth year and Dentists who were not willing to participate were excluded from the study.

Sample size calculation: The study population was selected using convenient random sampling. Sample size was assessed using G* power software (16).

Questionnaire

A self-structured, close-ended, Questionnaire [Annexure 1] was originally developed by chief investigator and the research team. The difficulties in understanding each question, its inference was critically analysed and minor modifications were made based on the feedback of subject experts in the final questionnaire. Cronbach’s alpha of 0.72 was regarded as satisfactory for ensuring internal reliability. A total of 21 questions divided into 4 sections, 4 questions on demographic data, 4 questions on Knowledge, 5 questions on Attitude and 8 questions on Practices related to C-shaped canals among dental students and dentists of Makkah region of Saudi Arabia.

The questionnaire was sent online to 503 dental students and dentists across Kingdom of Saudi Arabia. They were asked to make the best choice from the options available. The participant’s consent was obtained after assuring that their identity would be kept strictly confidential.

Statistical Analysis

The data were tabulated on Microsoft Excel (Microsoft, Redmond, WA, USA) and analysed using IBM Statistical Package for the Social Sciences (SPSS) version 22.0. Descriptive statistics followed by χ²-test was applied to test of variables in the questionnaire to determine their association. The significance value p-value ≤ 0.05 is considered as statistically significant.

Results

In the study population of 503 participants from Makkah region of Saudi Arabia, 68.4% (n=344) were males and 31.6% (n=159) were females, 25.2% (n=127) were undergraduate students and 74.7% (n= 376) were Graduate dentists, 76.1% (n=383) currently practice endodontics in their clinic or field, (Table/Fig 1). In this study, 63.2% (n=318) felt the most common tooth having C-shaped root canals in mandibular second molars, 59.4% (n=299) felt the type of population in which C-shaped root canals are found in Asians and 53.7% (n=270) have strongly agreed that knowledge of canal anatomy is helpful during access preparation of C-shaped root canals (Table/Fig 2). In the study population, 49.3% (n=248) have strongly agreed that they are proficient in diagnosing C-shaped root canals, 66% (n=332) felt Cone Beam Computed Tomography (CBCT) will be useful in diagnosing C-shaped root canals, 68% (n=342) have strongly agreed that use of magnification like operating microscope and loupes will be useful in managing C-shaped root canals, 33.4% (n=168) felt use of electronic apex locator will be useful in during working length measurement of C-shaped canals (Table/Fig 3). In the study population, 48.5% (n=244) felt use of crown down technique will be effective in cleaning and shaping of C-shaped root canals, 39.8% (n=200) felt use of ultrasonic irrigation will be effective irrigation and 72.8% (n=366) felt multiple visit endodontics is needed for successful management of C-shaped root canals, 25.8% (n=130) felt use of thermoplasticised gutta-percha compaction as a type of obturation to create a hermetic seal in C-shaped root canals, 36.4% (n=183) felt use of custom cast post to augment the strength of endodontically treated teeth in C-shaped root canals (Table/Fig 4).

Discussion

The unusual anatomic structure of the C-shaped root canal system can lead to difficulties during endodontic treatment ultimately affects prognosis (15); therefore, dentists should be familiar with this complex anatomy of the root canal. The prevalence of C-shaped canals differs among different ethnicities. In the present study, 59.4% of them felt that C-shaped root canals are frequently found in Asians, 22.9% in Africans and 10.1% in Europeans and 7% in Americans. This is in accordance with the study by Wang Y et al., where authors concluded prevalence of C-shaped canals is 41.27% in a native Chinese population using radiography and clinical examination under magnification (17) 8.5% in a European population (18) and 9.1% in Saudi Arabian population (19) which indicates its racial distribution.

Tratman EK observed that the C-shaped root morphology is frequently found in mandibular second molars. He named this morphology as the horse-shoe reduction form (20). In the present study, 63.2% of them felt that C-shaped root canals are commonly occur in mandibular second molars, 12.9% in maxillary first molars, 12.7% in mandibular second premolar and 3.2% in Mandibular third molar. This is in accordance with the study by Martins JNR et al., where authors concluded C-shaped canal have higher prevalence in mandibular second molars ranging between 36-43.1% using CBCT (21). The C-shaped canal anatomy has also been identified in maxillary first molars (0.12%), maxillary third molars (4.7%), mandibular third molars (3.5%-4%) and mandibular second premolars (1%) (22),(23),(24),(25).

A fundamental understanding of pulp chamber anatomy is very important to prevent endodontic mishaps. In the present study, 75.7% have strongly agreed the use of knowledge of canal anatomy such as the principle of colour change and the principle of orifice location are helpful during access preparation of C-shaped root canals. Cemento-Enamel Junction (CEJ) is an established landmark and the principle of colour change and the principle of orifice location can be effectively applied in C-shaped roots (6). In the present study, 66% have strongly agreed that CBCT is an effective tool in diagnosing C-shaped root canals; while 14.1 % felt conventional radiography is sufficient for diagnosing C-shaped root canals Preoperative intraoral periapical radiographs provide less significance in recognising C-shaped root canals (26). CBCT is more effective than conventional radiography in treatment planning in dentistry. This is in accordance with the study by replace with Lee TY et al., where authors concluded 36.8% of C-shaped canals were found in Korean population using CBCT (27).

Magnification devices are indeed an evolution from the conventional method of macrodentistry to high precision microdentistry. The use of magnification devices can lead to improved outcomes, thereby resulting in a higher quality of care. In the present study, the participants strongly agreed (68%) use of magnification like operating microscope and loupes is helpful during access preparation of C-shaped root canals. This is in accordance with the study by Wang Y et al., where authors concluded higher incidence of C-shaped canals was observed by using magnification devices like an operating microscope (41.27%), than using the conventional radiography (34.64%) or clinical examination (39.18%) alone (17).

Correct determination of working length is the critical step for successful endodontics. In the present study, 33.4 % felt the use of an electronic apex locator will be useful in working length determination of C-shaped root canals, while 27.8% felt the use of conventional radiography is sufficient. This is in accordance with the study by Jafarzadeh H et al., where authors concluded there was no significant differences between working length obtained by apex locator and radiography in-vitro study, although apex locator was more precise in confirmation of the working length (28).

In the present study, 48.5% felt the use of crown down technique will be useful for instrumentation of root canals, 13.5% felt the use of step back is sufficient, while surprisingly only 2.2% felt anti-curvature filling will be useful in biomechanical preparation. It has been reported that higher chance of root perforation at the thin lingual wall of C-shaped root canals in mandibular molars and the mesial walls of C-shaped root canals in mandibular first premolars during instrumentation of root canals (29). The main goal of root canal therapy is complete elimination of microorganisms from the root canal system and prevents recontamination. To achieve this biomechanical preparation must be combined with adequate irrigation of root canals (30). In the present study, 39.8% felt the use of ultrasonic irrigation will be effective in the debridement of root canals; followed by 20.1 % feel Quantec-E irrigation method will be useful in irrigation. This is in accordance with the study by Zhao Y et al., where authors concluded passive ultrasonic irrigation remove more debris than syringe and needle irrigation within the C-shaped canals of mandibular molars (31).

A three-dimensional obturation is crucial for the ultimate success of endodontic treatment. In the present study, 25.8% felt the use of thermoplasticised obturation method, whereas 22.7% felt the use of single cone technique is sufficient for obturation of C-shaped root canals. This is in accordance with the study by Kim HH et al., where authors compared warm gutta-percha obturation techniques with cold lateral condensation technique using simulated C-shaped root canals embedded in resin blocks, warm gutta-percha obturation techniques gives appropriate canal filling in C-shaped root canals (32).

In the present study, 36.4% felt the need of custom cast post, other 36% felt need of prefabricated post is sufficient if post is desired. If post placement is required, distal canal is preferred (33). The mesiobuccal and mesiolingual walls are very narrow, placement of posts in the mesiolingual and mesiobuccal areas of C-shaped root canal leads to perforation (29).

Limitation(s)

There are few limitations of the study namely level of education and quality of practice is different from dental students and practicing dentists as well as specialist dentists and the study population is not equally distributed among the participants.

Conclusion

Although, there was a good understanding and knowledge of the anatomical variations of the C-shaped root canal among dental students and dentists. However, there was a different treatment protocol practiced among different participants, especially during biomechanical preparation and obturation. The standard of care in managing C-shaped root canals effectively can be improved by continuing dental education programs and incorporation of advanced endodontics training among dentists. With the advancement of endodontic instruments and techniques, further research is necessary to manage the C-shaped root canal cases successfully throughout the endodontic procedures for a favourable long-term prognosis.

DOI and Others

DOI: 10.7860/JCDR/2022/52163.16082

Date of Submission: Sep 01, 2021
Date of Peer Review: Nov 24, 2021
Date of Acceptance: Jan 08, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 02, 2021
• Manual Googling: Jan 07, 2022
• iThenticate Software: Jan 19, 2022 (14%)

ETYMOLOGY: Author Origin