Knowledge, Attitude, and Practice Survey Among Endodontic Postgraduate Students Towards Scaffolds in Regenerative Endodontics
Harish Selvaraj1, Deepak Selvam2*
1 Postgraduate Student, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
2 Senior Lecturer, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
*Corresponding Author
Dr. Manish Ranjan,
Associate Professor, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha
University, Chennai 600077, Tamil Nadu, India.
Tel: +91- 9543445029
E-mail: manish@saveetha.com
Received: May 20, 2021; Accepted: August 11, 2021; Published: August 18, 2021
Citation:Harish Selvaraj, Deepak Selvam. Knowledge, Attitude, and Practice Survey Among Endodontic Postgraduate Students Towards Scaffolds in Regenerative Endodontics. Int J Dentistry Oral Sci. 2021;8(8):3960-3967. doi: dx.doi.org/10.19070/2377-8075-21000810
Copyright: Dr. Manish Ranjan©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Regenerative endodontics aims to regenerate the pulp-dentine complex which got damaged by infection, trauma
or developmental anomaly of immature permanent teeth with necrotic pulp. Regenerative endodontic procedures include
scaffolds, growth factors and stem cells. Adequate knowledge about each scaffold, their clinical applications and benefits are
essential for clinical success in regenerative endodontic procedures.
Aim: The aim of the present study is to investigate the knowledge, attitude and practice on scaffolds used in regenerative
endodontic procedures among the endodontic postgraduate students of India.
Methodology: A cross-sectional questionnaire based study was conducted in 2020 among Endodontic postgraduate students
of India. Survey questionnaires were prepared, using Google forms and it was distributed randomly to 236 Endodontic postgraduate
students. The obtained results were statistically analysed using SPSS and the graphs were plotted.
Results: All the postgraduate students have a general knowledge about what scaffolds are and their uses, however third year
endodontic postgraduate students have good knowledge and experience in using scaffolds in their clinical practice compared
to first and second year endodontic postgraduate students.
Conclusion: Good knowledge and positive attitude towards the use of scaffolds were observed among postgraduate students.
However, since most of the first and second year postgraduate students have not started using scaffolds in their practice,
a need for clinical training programmes would be efficient.
2.Introduction
3.Conclusion
4.References
Keywords
Scaffolds; Stem Cells; Growth Factors; Regenerative Endodontics.
Introduction
Dental pulp tissue is a highly innervated and strongly vascularized
tissue [1]. Pulp revascularization re-establishes the vascularity in
the root canal system. It induces angiogenesis in the endodontically
treated root canal. Pulp regeneration involves pulp revascularization
and restoration of functional odontoblasts and nerve
fibers [2]. Morphogens, progenitor or stem cells and the extracellular
matrix (ECM) scaffold are very important for regeneration.
Traditional treatment for immature permanent teeth with necrotic
pulp or teeth with apical periodontitis is by calcium hydroxide
which induces apical hard tissue barrier formation or apical MTA
plug before root canal filling [3, 4]. Increased risk of root fracture
is seen in immature permanent teeth with prolonged calcium hydroxide
dressing [5]. An apexification procedure does not have
the potential to restore the vitality of damaged tissue in the root
canal space and promote root maturation (thickening of the root
canal walls and/or apical closure) of immature permanent teeth
with necrotic pulp. So the revascularization procedure was introduced
in endodontics for the management of immature permanent
teeth with apical periodontitis or sinus tract [5, 6].
The term revascularization was replaced by revitalization as blood
vessels along with both hard and soft tissues were regenerated [7].
‘Regenerative endodontics’ was a term adopted by American Association of Endodontists in the year 2007. It relates to the triad
of tissue engineering, stem cells, biomimetic scaffolds, and bioactive
growth factors in the root canal space to regenerate the pulp
tissue damaged by infection , trauma or developmental anomalies
[7, 8].
Nygaard-Ostby was a pioneer in regenerative endodontics.
Nygaard -Ostby & Hjortdal in 1971 induced bleeding from the
periapical tissues into the debrided root canal space of the teeth,
which had a partial root filling. Histological examination of teeth
extracted after 9 days to 3 years revealed that fibrous connective
tissue and cellular cementum were formed in the apical canal
space of teeth originally containing vital pulp. But in teeth with
necrotic pulp there wasn’t any formation of repair tissue in the
apical canal space [9].
Regenerative endodontics can be defined as “biologically based
procedures designed to replace damaged tooth structures, including
dentine and root structures, as well as cells of the pulp
-dentine complex” [10]. Hence, regenerative endodontics aims
to regenerate the pulp-dentine complex which was damaged by
infection, trauma or developmental anomaly of immature permanent
teeth with necrotic pulp.
Regenerative endodontic procedures include scaffolds, growth
factors and stem cells. Scaffolds are three-dimensional (3D) porous
solid biomaterials designed which provide a spatially correct
position of cell location, they promote cell-biomaterial interactions,
cell adhesion, and ECM deposition, permit sufficient
transport of gases, nutrients and regulatory factors to allow cell
survival, proliferation and differentiation, biodegrade at a controllable
rate that approximates the rate of tissue regeneration and
provoke a minimal degree of inflammation or toxicity in vivo.
Growth factors regulate both transplanted and endogenous cells
in dental pulp-dentin regeneration. They are polypeptides or proteins
that bind to receptors on target cell surfaces. Stem cells are
undifferentiated embryonic or adult cells that divide indefinitely.
They have the ability to divide and produce new stem cells, as
well as differentiate through a specific molecular pathway. Adequate
knowledge about each scaffold, their clinical applications
and benefits are essential for clinical success in regenerative endodontic
procedures.
Hence, this cross sectional study aims to assess the knowledge
and opinion towards scaffolds used in regenerative endodontic
procedures among the endodontic postgraduate students of India.
Previously our team has a rich experience in working on various
research projects across multiple disciplines [11 - 25]. Now
the growing trend in this area motivated us to pursue this project.
Materials and Methods
Endodontic postgraduate students of India were asked to fill an
online survey. The students participated out of their own free
will. A total of three groups participated in the study. A total of
236 students participated in the study out of which 90 students
belonged to first year, 84 students belonged to second year and 62
students belonged to third year. The study was approved by the
Institutional Review Board at Saveetha Institute of Medical and
Technical Sciences.
Data Collection:
Each student was asked to fill an online survey via Google forms.
The exclusion criteria was that unwillingness to participate in the
survey and the students belonging to other courses. The questionnaire
consisted of 2 questions on demographics, 6 questions
on knowledge, 5 questions on attitude and 5 questions based on
practice.
Statistical Analysis:
The statistical analysis of data was done using IBM SPSS 1.0.0.
1406 64-bit edition software for Windows 10. Pearson chi-square
test was used to find if there was an association between the variables.
Results & Discussionn
236 complete responses were received from endodontic postgraduate
students in India. The overall responses of the survey
are given in Table 1.
Results of Figure 1. shows the students' knowledge on the procedures
included in Regenerative Endodontics. 93.3 % of the first
year, 100% of second and third year students opted for all the
above which included Scaffolds, growth factors and stem cells.
Figure 2. shows students knowledge on what scaffolds are, in
which 97.8 % of first year and 100 % of second and third year
students opted for three-dimensional (3D) porous solid biomaterials
used in tissue regeneration. Figure 3. shows how students
gathered information about scaffolds in which the majority of
first year students gathered by attending conferences and CDE
programmes (53.3%), second year students by reading articles
(78.6%) and third year students had it in their part of postgraduate
curriculum (90.3%). Figure 4. shows students’ knowledge
about the applications of scaffolds in regenerative endodontic
procedures in which majority of first (86.7%), second (95.2%),
third (100%) opted for all the options mentioned, that is to provide
structure to a developing tissue, secrete extracellular matrix,
allow cells to adhere, proliferate, differentiate. When the students
were asked about the type of scaffold which would be the most
effective 93.3 % first year, 57.1% of second year and 100 % of
third years felt that both natural and synthetic scaffolds are effective
(Fig.5). Majority of the first year students 49.9% were unsure
about if the porosity and size of pores influenced the success
rate, 88.1% of second year and 100% of third year students felt
that the porosity and size of the pores plays a role in its success
rate (Fig. 6). Most of the first (93.3%) and second (88.1%)
year students had not used any types of scaffolds in their clinical
practice and majority of students from third year (100%) have
used scaffolds (Fig.7). The most commonly preferred scaffold for
the revascularization of necrotic immature permanent teeth with
open apex by first year students was platelet- rich plasma (61.9%),
platelet- rich fibrin was opted by second year students (45.2%)
and third year students (90.3%) (Fig.8).
For management of large periapical lesions majority of first year
students (51.1%) and third year students (83.9%) preferred platelet-
rich fibrin and 81% of second year students preferred a combination
of platelet concentrate along with bone grafts (Fig.9).
Platelet- rich fibrin was preferred by majority of first (57.8%) and
second (47.6%) for the management of periodontal-endodontic
lesion while third year students (87.1%) preferred a combination
of platelet concentrate along with bone grafts (Fig.10). First
(64.4%) and second (76.2%) year students rarely treat necrotic immature
permanent teeth while third year (93.5%) students opted
sometimes (Fig.11). Majority of the postgraduate students had a
positive attitude towards recommending scaffold as a treatment
for tissue regeneration to their patients (Fig.12). Most of the first
(80%) and second year (78.6%) postgraduate students were unsure
about patients' attitude towards acceptance of regenerative
endodontic procedures using scaffolds while majority of third
year students (87.1%) felt that patients attitude would be positive
regarding treatment using scaffolds (Fig.13). On questioning
about the influence of treatment cost on treatment acceptance by
patients, the majority of second (57.1%) and third (93.5%) students
felt the high cost of scaffolds influences treatment acceptance
by patients and first year (54%) students felt it may influence
treatment acceptance (Fig.14). Majority of the postgraduate students
had a positive attitude towards recommending regenerative
endodontic procedures over dental implant therapy (Fig.15). The
reliability of scaffold therapy was found to make it more likely
to recommend scaffold therapy to patients by first (71.1%) and
second (76.2%) year students while third year students opted for
treatment effectiveness (87.1%) (Fig.16).
The present study is a survey of endodontic postgraduate students
towards regenerative endodontic procedures. It has given us
a better understanding of the ethical opinions, beliefs, and judgments
regarding the delivery of regenerative endodontic therapies
to dental patients. The survey's findings were largely optimistic,
with the majority of students agreeing that regenerative therapy
could be included in dental treatments and tissue engineering will
improve periapical tissue healing after nonsurgical root canal care.
The marvel of Regenerative endodontic procedures is that it helps to clinically treat immature teeth and simultaneously aids
in developing the root. It is especially helpful in the case of immature
teeth that are subjected to dental caries, trauma or even
anatomical anomalies. Teeth of the former sort have been treated
by means of apexification wherein calcium hydroxide is placed
over a significant period of time. The protocol adhered to is irrigation
with sodium hypochlorite followed by placement of an
intra-canal antibiotic paste. This is done without any mechanical
debridement. Invoking periapical bleeding into the space of the
canal which will then turn into a clot and ultimately serve as a
pulp tissue scaffold that will help advance wound healing have
also been suggested3. The advantage that periapical bleeding has
is that blood, containing numerable platelet- derived factors, will
drive fibrin scaffold, blood-derived bioactive growth factors and
mesenchymal stem cells into the root canal space. This stem cell
and growth factor combination will behave as a matrix for tissue
engineering.
It is imperative that clinicians these days are knowledgeable and
up-to-date about regenerative endodontics and its advancements
to facilitate decision making for patients’ treatment.
Regenerative endodontic therapies including periapical bone healing,
continued root development in immature teeth, pulp tissue
revitalization within a root canal, and tooth reimplantation were
all valuable treatments. The postgraduate students were optimistic
about the profession's future, including the incorporation of regenerative
therapy and the potential benefits to patients.
The increasing number of Regenerative Endodontic Procedures
(REPs), stem cell therapies, and tissue engineering articles reported
in scientific journals [26] , discussed at conferences, and
research findings disseminated in news media was likely a key factor
in the survey participants' strong general enthusiasm for the
potential use of scaffolds in clinical practice. However, since most
of the participants of the survey have not used any scaffolds in
clinical practice, a training programme would be sufficient to encourage
the use of scaffolds. Almost all of the participants agreed
that scaffolds could be used in dentistry, and the majority would
be able to receive through training programmes. The treatment
reliability and safety of scaffolds would make the students prefer
regenerative endodontic therapy. It is reasonable to assume that
these students would be some of the first to be delivering regenerative
therapies to their patients.
A majority of students read scientific dental journals, in their PG
curriculum and by attending seminars about scaffolds to gather
information regarding regenerative endodontic therapy indicating
that they were well-educated in recent advancements and research
in the field of dentistry.
Many of the respondents were aware of the potential therapeutic
benefits of REPs and their choice of scaffolds varied among the
postgraduate students for use in different clinical scenarios such
as revascularization of necrotic immature permanent teeth with
an open apex, for the management of a large periapical lesion
and periodontic-endodontic lesions. This desire to undergo further
training reflects students' support of new therapies as well as
their appreciation of these therapies' ability to offer a higher level
of care to their patients.
Many students, however, believed that the most significant barrier
to patient acceptance of these new regenerative therapies would
be their high cost. The majority of students believed that regenerative
dental treatments would be a better treatment choice than
dental implant therapy, and that they would be able to save teeth
and dental tissues for use in regenerative dental treatments. The
majority of students were willing to provide regenerative therapies.
This represents students' commitment in providing their patients
with the best possible care. However most of the first and
second year postgraduate students have never used scaffolds in
their clinical practice and Postgraduate students may find it difficult
to practice these procedures more frequently due to a lack of
training. The lack of enough materials to carry out the procedure
may also be a major reason for not practicing. The current study
results were similar to study done by [27, 28] and [29] which reflected
the willingness of dentists to undergo training to practice
regenerative endodontic procedures. Hence, training programmes
regarding the usage of scaffolds in different clinical procedures
would be efficient to encourage its use by students.
Our institution is passionate about high quality evidence based
research and has excelled in various fields [15, 30-39].
Table 1. Questionnaires included in this survey and their responses.
Figure 1: Bar graph represents the association between the year of study and their opinion regarding the procedures in regenerative endodontic therapy. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. Following are included in regenerative endodontic procedures Scaffolds (Blue), Stem cells (Green), Growth Factors (Orange) and All of the above (Red). Most of the endodontic postgraduate students answered all the above i.e Scaffolds, stem cells and growth factors are included in regenerative endodontic procedures. Chi square test was done and the association was significant (p-value=0.007; p<0.05)
Figure 2: Bar graph represents the knowledge of first, second and third year endodontic postgraduate students about what scaffolds are. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. Three dimensional porous solid biomaterials used in tissue regeneration have been indicated in Blue and dental restorative materials indicated in Red. The results were not statistically significant (p=.195; p>0.05) showing that most of the students had knowledge on what scaffolds are.
Figure 3: The above bar graph represents the method by which postgraduate students of various years gathered information about scaffolds in regenerative endodontics. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. Based on the results, first year students acquired their knowledge by attending conferences and CDE programmes, second years through article reading and finally third years via their curriculum.
Figure 4: The bar graph represents the level of comprehension of postgraduate students about the uses of scaffold in regenerative endodontics. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. According to the graph above, students of all three years selected all of the above i.e. both provide structure to a developing tissue and to allow cells to adhere, proliferate and differentiate.
Figure 5: Bar graph portrays the insight postgraduate students have about the type of scaffold that is effective in regenerative endodontics. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. According to the graph above, students of all three years selected both i.e. synthetic and natural.
Figure 6: The achieved results from the bar graph above portrays the knowledge of postgraduate students about the role of porosity and size of scaffold in its success rate. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. The results show that a large majority of students from second and third years selected ‘yes’ i.e. the porosity and size of scaffold does matter in its success rate. Whereas the first years have mixed answers, with the option ‘unsure’ predominating.
Figure 7: The question posed was to evaluate the usage of scaffolds by postgraduate students of various years. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. We can conclude that neither first or second years widely utilise scaffolds in their work. On the other hand, all participating third year postgraduates have used scaffolds for regenerative endodontic procedures
Figure 8: The bar graph above depicts the decisions of postgraduates on selecting the adequate scaffold for revascularization of necrotic immature permanent teeth with an open apex. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. We can study that platelet-rich fibrin and platelet-rich plasma are common answers. First years had selected platelet-rich plasma(PRP), third years selected platelet-rich fibrin(PRF) and second years had chosen platelet-rich fibrin(PRF).
Figure 9: Bar graph represents the various decisions of postgraduate students on selecting adequate scaffold for management of a large periapical lesion. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. We can conclude that most first and third years have responded with ‘platelet-rich fibrin’ (PRF) as their common answer, while the majority of second years have selected ‘combination of platelet concentrations along with bone grafts’.
Figure 10: The above bar graph illustrates the selection of scaffold for management of periodontic-endodontic lesions by postgraduates. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. It is shown that a greater part of first and second years have selected ‘platelet-rich fibrin’ (PRF). Most of the third years have opted ‘combination of platelet concentrations along with bone grafts’ as their answer.
Figure 11: The above bar graph depicts the answers of students for how often they treat necrotic immature permanent teeth. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. First and second years have predominantly chosen ‘rarely’, while third years have chosen ‘sometimes’ as their respective answers.
Figure 12: Bar graph represents the opinion on recommendation of scaffold to patients as a treatment option for tissue regeneration. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. Majority of third year students strongly recommended scaffold as a treatment for tissue regeneration whereas first and second year students opted for maybe.
Figure 13: The displayed bar graph explains the selection of a particular advantage that would lead to the selection of the scaffold for patients by postgraduates. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. The first and second years have selected ‘safety and reliability’, whereas third years selected ‘ treatment effectiveness’ to treat necrotic immature permanent teeth.
Figure 14: The bar graph displays the perspective of postgraduates on whether the high cost of the scaffolds influences patient treatment acceptability rate. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. Both second and third years have mainly opted with ‘yes’. First years have opted ‘maybe’, although there are some who selected ‘yes’ too.
Figure 15: The bar graph represents the opinion of postgraduates on whether they would recommend regenerative procedures over dental implant therapy to patients. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. A mass majority of all the years have chosen ‘yes’ as a common answer.
Figure 16: The displayed bar graph explains about the selection of a particular advantage that would lead to the selection of the scaffold for patients by postgraduates. X-axis represents the year of postgraduate study and Y-axis represents the number of participants. The first and second years have nominated ‘safety and reliability’, whereas third years have nominated ‘ treatment effectiveness’ often to treat necrotic immature permanent teeth.
Conclusion
Regenerative Endodontic Procedures have emerged as good
choices for the treatment of pulpal necrosis of immature teeth.
The majority of the students were aware of the characteristics
of different scaffolds, allowing them to choose the most appropriate
one for successful outcomes. Good knowledge and positive
attitude towards the use of scaffolds were observed among
postgraduate students. However, since most of the first and second
year postgraduate students have not started using scaffolds
in their clinical practice, a need for clinical training programmes
would be efficient.
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