Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : ZC07 - ZC13 Full Version

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

Published: March 1, 2022 | DOI:
Siddiq Ahmed, Abdulrahaman Mohammed Ali Aldughaysh, Baheej Ghazi Hamzah Alhazmi, Faisal Saud Mohammed Alsubhi, Zeyad Tariq Hilal Ashour

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.

Correspondence Address :
Dr. Siddiq Ahmed,
Faculty of Dentistry, Ibn Sina National College for Medical Studies, AL Mahajar
District, Jeddah, Makkah, Saudi Arabia.


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 25th September 2020 to 25th 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).


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.


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).


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).


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.


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.


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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

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

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