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Table of Contents
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 50-55

Standards of practice among endodontists in Kerala, India: An exploratory study

1 Department of Conservative Dentistry and Endodontics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission12-Jan-2022
Date of Acceptance11-Mar-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Asha Joseph
Department of Conservative Dentistry and Endodontics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, AIMS, Ponekkara PO, Kochi, Kerala 682041
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMJM.AMJM_7_22

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Background: The field of endodontics is greatly evolving with the brisk entry of not just new materials but also numerous technology-based advances. Factors governed by the practitioner such as the canal preparation technique, the disinfection regimes followed, the standard of obturation, and the quality of coronal and apical seal all in turn greatly influence the prognosis of the endodontic treatment. Objective: To assess the attitude concerning the materials and techniques used during endodontic treatment among the endodontists in Kerala. Materials and Methods: An online questionnaire-based cross-sectional study was done among endodontists in Kerala. The questionnaire assessed several key aspects of endodontic practice. A comparison was made based on the nature of practice and years of practice. Results: A total of 165 responses were obtained. A high percentage of participants (>75%) routinely employed preoperative radiographs. A combination of apex locators along with radiographs was most preferred for working length determination, and calcium hydroxide was the most preferred root canal sealant. Almost half of the endodontists did not use any form of magnification. Conclusion: Despite several booming advances in technology, endodontists still do not strictly follow the implementation of important regimes such as the incorporation of magnification or use of a rubber dam in their practice, which still needs to be meticulously incorporated into practice, which would raise the standards of clinical practice.

Keywords: Endodontists, isolation, practice standards

How to cite this article:
Joseph A, Ramanarayanan V, Venugopal K, Prabath Singh V P, Dhruvan K, Sagar K. Standards of practice among endodontists in Kerala, India: An exploratory study. Amrita J Med 2022;18:50-5

How to cite this URL:
Joseph A, Ramanarayanan V, Venugopal K, Prabath Singh V P, Dhruvan K, Sagar K. Standards of practice among endodontists in Kerala, India: An exploratory study. Amrita J Med [serial online] 2022 [cited 2023 Mar 30];18:50-5. Available from: https://ajmonline.org.in/text.asp?2022/18/2/50/349263

  Introduction Top

A major goal of endodontic therapy is the elimination of microorganisms and infected pulp tissue. Because of the anatomical complexities of the pulpal space, a certain amount of organic tissues and bacteria still manage to thrive inside root canal systems even after appropriate instrumentation.[1] The current clinical practice of endodontics revolves around a wide horizon of new technological advances and materials.[2] A wide array of endodontic armamentarium is available for use in the field of endodontics today. However, a sound endodontic practice is largely dependent on the selection and utilization of materials and techniques supported by research-based evidence.

Multiple factors such as age, gender, preoperative vitality, and periapical pathology determine the prognosis of an endodontically treated tooth. Factors governed by the endodontist such as the technique of canal preparation and the position of apical seal also influence the outcome.[3] The success rate of endodontic treatment is generally higher when performed by specialists as compared to general practitioners.[4] The attitudes and practice of endodontists toward various treatment protocols play a pivotal role in the success or failure of the treatment. With rapid technological advances, newer and improved dental materials and instruments are available by the day, and hence, there is no single standard of care that can be applied for treatments. The choice of materials is also dependent on various factors such as the location of practice, availability of newer materials, cost, operator comfort and preferences, evidence-based choices, etc. Quite predictably, there could be wide variations in the standards of practice among endodontists in different countries of the world and also among different regions within the country. Thus, a survey among different endodontists in a defined region would help assess the current endodontic practices and determine if it is in tune with the current endodontic practice trends.[5] The objective of this study was to determine adoption rate with which these new endodontic technologies and materials are being employed by endodontists in Kerala in their routine clinical practice.

  Materials and Methods Top

This online questionnaire-based closed survey was conducted among endodontists practicing in the state of Kerala, India, from May 2020 to January 2021. The sampling frame constituted members affiliated to Conservative and Endodontic Society of Kerala (CAESOK), the largest professional association of endodontists in the state. The questionnaire was adapted from a similar study done by Kohli et al.[3] and Gulzar et al.[5] The modified questionnaire was validated using content validity index (CVI) by a group of five experts in the field of endodontics. Because the initial CVI was 50%, the questionnaire was modified based on the comments provided by the experts. The questionnaire was distributed in online mode (Google forms) to all members of the association through its social media (WhatsApp) handle. Information regarding the study and the investigators was provided in the first page of the online questionnaire, and consent was obtained from willing participants following which the questionnaire was accessible. The respondents could access the questionnaire only if they consented to participate in the study. The study excluded those members of the society who were not practicing currently. No personal identifiers (name and email) were asked to ensure anonymity. Only the investigators had access to the responses of the Google forms. The study protocol was approved by the Institutional Ethics Committee (IRB-AIMS-2020-102).

The survey consisted of two sections: the first was the consent form followed by the questionnaire consisting of 15 questions concerning different aspects of endodontic treatment including demographic details, viz., gender, years of practice (less than or more than 5 years of practice), and nature of practice (clinics/hospitals and dental teaching institutions), use of radiographic techniques, preferred method of isolation, working length determination technique used, technique of root canal instrumentation, choice of irrigant and intracanal medicament, preferred obturation technique, and method of magnification employed. The observed data were tabulated, coded, and analyzed using IBM SPSS Version 20 for Windows. Descriptive statistics were expressed as mean ± standard deviation for continuous variables and frequency and percentages for categorical variables. A comparison between study groups (years of practice and nature of practice) for different questions (endodontic practices) were done using Chi-square test. A P value of less than 0.05 was considered statistically significant.

  Results Top

A total of 297 members were approached for participation of which 165 responded (Response rate: 55.5%). Eight respondents who did not practice dentistry currently and eight responses with missing data for few questions were excluded. The final study sample had 149 participants with 53.7% men (n = 80) and 46.3% women (n = 69) [Table 1]. For the purpose of comparison, participants were grouped based on the years of practice and nature of practice. About 72.5% of the endodontists had less than 5 years of experience and 27.5% had more than 5 years of experience. Also, among the participants, 51% of the endodontists were practicing in dental teaching institutions (both private and government), while the remaining 49% were engaged in clinical practice (both private and government).
Table 1: Characteristics of study participants

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It was observed that endodontists who had greater than 5 years of experience always took preoperative radiographs (85.45%) compared with those with less than 5 years of experience (76.9%). With regard to the nature of practice, it was noted that 81.6% and 76.7% of endodontists practicing in teaching institutions and clinics, respectively, always took preoperative radiographs [Table 2]. There was no statistically significant difference among the groups.
Table 2: Endodontic practices

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The evaluation of isolation protocols revealed that most endodontists preferred a combination of cotton rolls and suction over rubber dam irrespective of the years of experience and nature of practice [Figure 1]. The treatment modality for emergency pain cases opted by most endodontists was to do an access opening along with antibiotics and analgesics. There was no statistically significant difference in the treatment modality followed based on the years of experience or nature of practice.
Figure 1: Preferred method of isolation among study groups

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Overall, step-back technique was the most commonly followed technique of biomechanical preparation over other techniques. This technique was more popular among practitioners having less than 5 years of experience (45.4%) compared with their more experienced counterparts (22%). The difference was statistically significant. The method of working length determination most commonly followed was the use of a combination of apex locators along with radiographs. It was observed that this technique was more commonly followed by endodontists who had more than 5 years of experience (75.6%), compared with those with less than 5 years of experience (64.8%). However, the difference was not statistically significant.

Most endodontists opted for the use of different irrigants such as saline, sodium hypochlorite, and chlorhexidine during biomechanical preparations rather than sodium hypochlorite alone. This was the regime followed by most endodontists who had greater than 5 years of experience (80.5%). The preferred needle design among most endodontists was side-vented especially among endodontists with greater than 5 years of experience (73.2%).

Calcium hydroxide was the most preferred intracanal medicament irrespective of the years of experience and nature of practice, while lateral condensation was the most favored obturation technique irrespective of the number of the years of experience or nature of practice. The sealer most often used for obturation was calcium hydroxide-based sealers.

A large proportion of endodontists did not use any form of magnification at all in their routine practice, and among them who used, loupes were preferred over microscope [Figure 2]. A statistically significant difference was found in the nature of practice with endodontists working in dental teaching institutions using more microscopes than independent practitioners.
Figure 2: Use of magnification options among study groups

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  Discussion Top

This study evaluated the preference with regard to the techniques and materials most often utilized by various endodontists in the state of Kerala. The CAESOK was selected because it had the largest representation of endodontists in the state, and the members were associated with dental teaching institutions, private practice, and even a combination of both. An attempt was made to evaluate if there was a difference in the endodontic practice trends among academicians and private practitioners as it is usually believed that endodontists in dental teaching/academic institutions would be more updated with the latest technological advancements and implement in their practice.

Given the fact that this particular study was exclusively conducted among endodontists sets apart from the norm that most available studies so far were assessed among the dental practitioners and endodontists or among dental practitioners alone, not many studies have so far tried to evaluate the current practicing trends among endodontists themselves, which is notably crucial.

The extent and severity of periapical pathology can be interpreted with the help of preoperative radiographs, which would enhance the diagnosis as well.[6] This study gauged the fact that the majority of endodontists took preoperative radiographs before commencing any endodontic treatment, which helps in proper case selection, assessing canal morphology, and number of canals present. In this study, it was interesting to observe that endodontists with greater experience always took preoperative radiographs. This could be probably due to clinical expertise gained over the years by extensive practice. Hence, it could be clearly stated that preoperative radiographs are essential in elevating the accuracy of the endodontic procedure.

Proper isolation is mandatory for successful endodontic treatment. It was appalling to realize that the majority of endodontists used cotton rolls and suction tips during endodontic treatment. Based on the years of practice, only 39% of endodontists with more than 5 years of experience used rubber dams, which is quite surprising. Only 28.9% of academic institutions employed rubber dams in their isolation regimes. In a study conducted in a dental teaching institution in Odisha, 70% of endodontists reported the use of rubber dams for root canal treatments. However, the use of rubber dam by general dentist and other specialists was very low.[7] An appropriately applied rubber dam is considered as the “golden standard of care” in endodontic practice.[8] A clinical survey conducted by a group of researchers from Taiwan confirms that the application of rubber dam during root canal treatment could significantly increase the survival rate after initial root canal therapy.[9] Similar observations were endorsed in the study conducted by Cochran et al.[10]

The preparation of root canal systems includes enlargement and shaping of complex endodontic space together with its disinfection. An immense range of instruments and techniques has been developed for this critical purpose. This study revealed that most endodontists preferred step-back technique over other techniques of biomechanical preparation. Similar results were reported by Shrestha et al.[11] where 90% of the practitioners used step-back technique, while only 23% only used crown down technique.

The most commonly deployed technique of working length determination was the use of apex locators followed by radiographic confirmation for determining the working length. This is in agreement with the study done by Jenkins et al.[12] A clinically precise estimation of working length is decisive for the success of endodontic therapy.[13]

Among various irrigation protocols followed, it was noteworthy to observe that most endodontists used a variety of irrigants such as sodium hypochlorite, chlorhexidine, EDTA, and saline during different stages of biomechanical preparation. Irrigation plays a crucial role in the disinfection of the root canal system. Sodium hypochlorite is the most widely used root canal irrigant because it has an excellent tissue dissolution potential and antibacterial action. However, the presence of dentin, tissue debris, and blood can limit the antibacterial action. Hence the use of additional irrigants along with sodium hypochlorite has been suggested to circumvent this problem.[14] The side-vented needle is the most popular needle design as observed from the study. Calcium hydroxide was the most preferred intracanal medicament among other intracanal medicaments among most endodontists without any difference based on the years of experience or nature of practice.

Lateral condensation technique was the most common obturation technique used along with the use of calcium hydroxide-based sealers. It has been suggested that the high pH of calcium hydroxide in the root canal promotes a state of alkalinity in adjacent tissues, which in turn favors the repair of periradicular tissues.[15]

The use of magnification in endodontics has proven to greatly improve the technical accuracy and performance standards in clinical practice.[16] It was quite surprising to observe that the majority of the endodontists did not use any form of magnification in their endodontic practice. A study conducted in Chennai, India, reported that less than 50% of endodontists use magnification in their routine practice.[17] Reasons for not using any form of magnification could be due to its high cost and relative prolonged learning curve. As per this study, loupes were the preferred choice of magnification compared with microscopes in endodontic practice. Findings were similar to the study conducted in Riyadh city by Elrashid et al.[18]

One of the major limitations of this study could probably be the fact that all endodontists practicing in the state of Kerala were not included as an affiliation to the organization is optional. However, being the largest professional body of endodontists in the state, we presume to have obtained a representative sample. The response rate was 55.5%, though favorable for an online survey could have been improved.

  Conclusion Top

It is widely accepted that the effectiveness and efficiency of endodontic procedures largely depend on how much adherence is adopted by the endodontists toward fine-tuning the protocols with established guidelines in clinical research. The present study clearly found that although there are indeed certain protocols that have been conscientiously followed by the endodontists in Kerala, there is a lack of attention and acquaintance of advanced techniques that would definitely raise the quality of endodontic practice. Hence it is imperative that the practitioners must raise the standards of their clinical practice by intensely implementing the myriad of technology and materials available for endodontic practice based on research-based evidence.

Clinical significance

To suggest reforms in the current endodontic practice for an overall improvement in the treatment outcome among the wide array of techniques and materials available in the field of endodontics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hulsmann M, Peters OA, Dummer PMH Mechanical preparation of root canals: Shaping goals, techniques and means. Endod Topics 2005;10:30-76.  Back to cited text no. 1
Gupta R, Rai R The adoption of new endodontic technology by Indian dental practitioners: A questionnaire survey. J Clin Diagn Res 2013;7:2610-4.  Back to cited text no. 2
Kohli A, Singh S, Podar R, Dadu S, Kulkarni G A comparative evaluation of endodontic practice trends in India: “The Mumbai study.” Indian J Dent Res 2014;25:729-36.  Back to cited text no. 3
Alley BS, Kitchens GG, Alley LW, Eleazer PD A comparison of survival of teeth following endodontic treatment performed by general dentists or by specialists. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:115-8.  Back to cited text no. 4
Gulzar R, Kalra D, Shah H, Bhate P Assessment of practice of endodontic treatment protocols among dental practitioners in Mumbai and Navi Mumbai: A questionnaire-based survey. Int J Sci Study 2016;4:160.  Back to cited text no. 5
Yusof ZYM, Nambiar P Radiographic considerations in endodontics. Malays Dent J 2007;28:51-8.  Back to cited text no. 6
Shashirekha G, Jena A, Maity AB, Panda PK Prevalence of rubber dam usage during endodontic procedure: A questionnaire survey. J Clin Diagn Res 2014;8:ZC01-3.  Back to cited text no. 7
Ahmed HM, Cohen S, Lévy G, Steier L, Bukiet F Rubber dam application in endodontic practice: An update on critical educational and ethical dilemmas. Aust Dent J 2014;59:457-63.  Back to cited text no. 8
Lin PY, Huang SH, Chang HJ, Chi LY The effect of rubber dam usage on the survival rate of teeth receiving initial root canal treatment: A nationwide population-based study. J Endod 2014;40:1733-7.  Back to cited text no. 9
Cochran MA, Miller CH, Sheldrake MA The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4.  Back to cited text no. 10
Shrestha D, Dahal M, Karki S An endodontic practice profile amongst general practitioners in Kathmandu: A questionnaire survey. J Coll Med Sci Nepal 2013;9:40-50.  Back to cited text no. 11
Jenkins SM, Hayes SJ, Dummer PM A study of endodontic treatment carried out in dental practice within the UK. Int Endod J 2001;34:16-22.  Back to cited text no. 12
Hoer D, Attin T The accuracy of electronic working length determination. Int Endod J 2004;37:125-31.  Back to cited text no. 13
Thaha KA, Varma RL, Nair MG, Sam Joseph VG, Krishnan U Interaction between octenidine-based solution and sodium hypochlorite: A mass spectroscopy, proton nuclear magnetic resonance, and scanning electron microscopy-based observational study. J Endod 2017;43:135-40.  Back to cited text no. 14
Miglani R, Shankar , Indira R, Ramachandran S An in vitro evaluation of calcium hydroxide root canal sealers and its effect on six microorganisms. J Conserv Dent 2007;10:99-103.  Back to cited text no. 15
Low JF, Dom TNM, Baharin SA Magnification in endodontics: A review of its application and acceptance among dental practitioners. Eur J Dent 2018;12:610-6.  Back to cited text no. 16
Auswin MK, Ramesh S Knowledge, attitude, and practice survey on the use of dental operating microscope in endodontics: A cross-sectional survey. J Adv Pharm Educ Res 2017;7:320-2.  Back to cited text no. 17
Elrashid AH, Alderaa KJ, Alissa HA, Almadhi WH, Bawazir HS, Alsougi SS, et al. Perceived effectiveness about endodontic practice among private general dental practitioners in Riyadh city, Saudi Arabia. J Family Med Prim Care 2020;9:2426-30.  Back to cited text no. 18
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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