Knowledge Attitude And Perception Of Regenerative Endodontic Procedure Among Specialist And Dental Practitioners

Keywords

Regenerative Endodontic Procedure; Root Canal; Scaffold; Dental Practitioner and Specialist; Innovative Technique; Eco-Friendly.

Introduction

Regenerative endodontics is one of the most remarkable advancements in our specialty. The idea that one can replace damaged structures and regain functionality in previously necrotic and infected root canal systems has been groundbreaking. Regenerative endodontic treatment is a procedure that involves disinfection of the root canal with the use of antibiotics [1]. The purpose of pulp treatment is to maintain the tooth structure intact in order to preserve optimal function [2]. Especially, in case of immature permanent teeth, maintaining the pulp vitality is essential for continuous root development and apical closure [3]. Immature Necrotic Permanent Teeth is removal of the necrotic pulp tissue from the canal with minimum canal preparation is required because the canal walls are thin and over-preparation can weaken the root structure, making it susceptible to fracture [4]. If the pulp of immature permanent teeth is infected, apexification that includes removal of the infected pulp and application of calcium hydroxide has been performed traditionally [5]. Traditional approaches of calcium hydroxide apexification and apical barrier techniques with mineral trioxide aggregate (MTA) have been used in the treatment of immature teeth with pulp necrosis though generally there is no further root development so the roots remain thin and fragile with a higher risk of fracture and tooth loss. Recently, it has been suggested that regenerative endodontic protocols (REPs) that utilize endogenous stem cells that are introduced in the canal by lacerating the periapical tissues to fill the canal with blood should be used for the treatment of immature teeth with pulp necrosis [6].

When the tooth is damaged by trauma, pulp regenerative endodontic treatment is performed because the pulp tissue is uninfected [7]. It results in complete root development after a short-term treatment procedure [8]. It has a high success rate. When compared with MTA apexification, studies have reported similar success and survival rates for regenerative endodontics, in the range of 90-100% [9]. It's a biologically based approach that induces bleeding from the periapical region into the canal, thus generating vital tissue that provides a natural defense against reinfection [10]. Radiographs such as periapical, bitewing and/or cone beam computed tomography are taken and plan is made for the treatment. It is designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp-dentin complex [11].

Pulpal status and degree of root development are major factors in treatment planning for teeth requiring vital pulp treatment or root canal treatment [12]. Regenerative endodontic procedures are diverse and can include direct pulp capping, revascularization, apexogenesis, apexification, and even stem cell therapy and tissue engineering [13]. The key elements of regenerative endodontic procedure are stem cells, growth factors and scaffolds. Scaffolds are three-dimensional porous solid biomaterial. An ideal scaffold should be high porosity and an adequate pore size are necessary to facilitate cell seeding and diffusion throughout the whole structure of both cells and nutrients and should allow effective transport of nutrients, oxygen, and waste [14]. The scaffolds can be based on degradability of matrices, forms, presence or absence of cells and origin. There are also natural scaffolds, such platelet rich plasma and platelet rich fibrin [15]. There are various other techniques, root canal revascularization via blood clotting, postnatal stem cell therapy, pulp implantation, scaffold implantation, injectable scaffold delivery, three dimensional cell printing and gene delivery [15]. The difference between repair and regeneration is regeneration is that it is completely necrotic tissue and after the treatment it closely resembles pulp tissue [16].

In a previous survey, practitioner interest in delivering regenerative endodontic procedures has been growing, with 96% of endodontists being willing to incorporate regenerative therapies into treatments [17]. In a previous survey, 156 endodontic postgraduate students were surveyed [18]. In another survey, 200 copies of the questionnaire were circulated, containing 23 questions regarding knowledge and opinions about the use of REP's and their application in a clinical scenario [19]. In another survey, 100 copies of a survey were circulated, and 56 completed surveys were returned anonymously [17]. In another survey, an online questionnaire comprising 20 questions was distributed amongst the dental professionals of Mangalore. A total of 448 dental professionals responded [20]. A total of 105 responses were collected, Soft copies of the questionnaire were posted on online dental forms dedicated to dental postgraduates presently undergoing training in various colleges in India [21]. In another survey, a total of 850 participants completed the survey, representing a 20.9% response rate.

In future, regenerative endodontic procedures will become very popular and it is speculated to see unparalleled advances in this field. Hence, it is important to understand what the future endodontists think in this regard. Our team has extensive knowledge and research experience that has translated into high quality publications [22-41]. The aim of the survey was to evaluate the knowledge, attitude and practice on regenerative endodontic procedure among dental practitioners and specialists.

Materials and Methods

Study setting:

This survey was a prospective observational study. The advantages of this study were economical, easy to create, widespread, gather large data and quick interpretation. It involves homogeneous population, response bias and creates survey fatigue were the cons of the study. This study has been approved by the scientific review board, Saveetha dental College, Chennai.

Sampling for survey:

The sampling method for the survey conducted was simple random sampling. Sampling methods may contain a certain bias, hence measures are taken to minimise the sampling bias. The measures include checking internal and external validity, also by minimising error in question and avoiding leading questions.

Data collection:

A survey was conducted across dental colleges of western part of India in February 2021. A closed-ended questionnaire, comprising 21 questions were asked. The questions were validated. These questions can be divided into three parts, namely knowledge, attitude, and practice. Based on responses from the endodontic postgraduate students to this multiple choice-based questionnaire, the survey was analyzed. The survey was circulated using an online Google form link and the data was collected and represented in the pie chart using SPSS software (version 23). Regenerative endodontic treatment, endodontics, knowledge, pulp, scaffolds are the output variables.

Analytics:

A statistical test was used which is descriptive statistics, chi-square test, pie chart and bar diagram. P-value was found out and correlation and significance were established. Age, height, sex, neighbour, family and friends are the independent variables. Education, knowledge, attitude, perception and occupation are the dependent variables.

Results

Figures

×

Figure 1:

Close

Figure 1. Represents the distribution to know about regenerative endodontic procedure, where 59.52 % said yes (green), and 40.48% said no (blue).

×

Figure 2:

Close

Figure 2. Represents the distribution of how many months does it take for a successful regenerative endodontic procedure, 15.48% said more than 12 months ( blue), 33.33% of the people said that more than 3 months (green), 51.19% said that more than 6 months (brown ).

×

Figure 3:

Close

Figure 3. Represents the distribution of participants based on the opinion on whether they have done regenerative endodontic procedure previously for their patients, where 77.38% responded yes (green) and 22.62% responded no (blue).

×

Figure 4:

Close

Figure 4. Represents the distribution of participants based on the opinion on whether regenerative endodontic procedure can serve as a feasible replacement of more aggressive treatment protocols, where 79.76% responded yes (green) and 20.24% responded no (blue).

×

Figure 5:

Close

Figure 5. Represents the distribution of challenges faced during regenerative endodontic procedure, where 8.33% said disinfection of root canal in immature teeth (blue), 22.6% said that growth factors (green ), 39.29% said scaffolds (brown), 23.81% to obtain a sufficient no of autogenous cells (purple), 5.95% said unpredictable outcomes (yellow ).

×

Figure 6:

Close

Figure 6. Bar charts representing association between gender and opinion on reason for not practising regenerative endodontic procedure. X axis represents gender and Y axis represents the number of participants who responded ‘i don't have sufficient knowledge regarding regenerative endodontic procedure’ (blue), ‘i don't have sufficient training to perform the treatment’ (green) and ‘i have not encountered any case before’ (brown). Both males and female population strongly agree that they don't have sufficient training regarding regenerative endodontic procedure, however, it is not statistically significant (Pearson’s chi square value = 2.969, df= 2, p value= 0.227).

×

Figure 7:

Close

Figure 7. Bar charts representing association between gender and opinion on best treatment in regenerative endodontic procedure. X axis represents gender and Y axis represents the number of participants who responded ‘immature apex with necrotic’ (blue), ‘periapical cyst with resolution’ (green), ‘persistent periapical infection’ (brown) and ‘root resorption’ (purple). Both males and female population strongly agree that immature apex with necrotic is best suited in regenerative endodontic procedure, however, it is not statistically significant (Pearson’s chi square value = 2.509, df= 3, p value= 0.474).

×

Figure 8:

Close

Figure 8. Bar charts representing association between gender and opinion on the fear of patients for not accepting regenerative endodontic procedures. X axis represents gender and Y axis represents the number of participants who responded ‘higher cost’ (blue) and ‘success rate’ (green). Males strongly agree that success rate is the fear of patients whereas females think that higher cost is the fear, however, it is not statistically significant (Pearson’s chi square value = 3.542, df= 1, p value= 0.060).

×

Table 1:

Close

Table 1.

Discussion

This survey was employed to evaluate the awareness, understanding, attitude, and knowledge regarding regenerative endodontic procedures among the dental practitioners and specialists. Since most of the recent research is diverted toward stem cell and regenerative dental procedures, we think that it is deemed necessary to have a survey from general dental practitioners and endodontists to know the enthusiasm for the incorporation of regenerative endodontic procedures into dental practices.

In the present survey, the age of the participants were asked. 63.10% were at the age of around 20-30 years, 27.38% of the respondents were between the age of 30-40 years and 9.52% of the respondents were above the age of 40 years. Out of 100 respondents, 54.8% were males and 45.2% were females. The number of years of experience as a dental professional was asked. For which, 47.6% of the respondents had 5-10 years of experience, 45.2% of the respondents had 0-5 years of experience and 7.1% said they had 5-10 years of experience. The specialisation of the dentist was asked and 44% of the respondents were dental practitioners, 41.7% of the respondents were dental specialists and 14.3% of the respondents were endodontists. When asked regarding the awareness of regenerative endodontic procedure, 59.5% said they were aware and 40.5% said no. Then we asked from where they knew about regenerative endodontic procedure. 38.1% said from conferences and seminars, 25% said they learnt it during their UG course, 15.5% said they learnt it during their PG course, 8.3% said from books and 6% were not aware about regenerative endodontic procedure. When the use of regenerative endodontic procedure was asked, 20.2% said Damaged dentine, 25% said Damaged pulp, 23.8% said Damaged enamel, 28.6% said all the above. When they know about regenerative endodontic procedures, 52.4% said Guided endodontic repair and 47.6% said True regeneration of physiological like tissue. A question regarding their knowledge on stem cells and its sources were asked. 63.1% were aware about stem cells and 36.9% said they were not aware. Regarding the sources of stem cells, 9.5% said dental pulp stem cell, 22.6% said stem cell from apical papilla, 23.8% said stem cell from periodontal ligament, 26.2% said all of the above and 17.9% said not aware. When the duration of successful regenerative procedure was asked, 33.3% said more than 3 months, 51.2% said more than 6 months and 15.5% said more than 12 months.

When asked whether they are aware that scaffold, stem cells and growth factor are included in regenerative endodontic procedure, 86.9% said yes and 13.1% said no. when asked about the opinion on whether regenerative endodontic procedure can serve as a practical and feasible replacement of more aggressive treatment protocols, 79.8% said yes and 20.2% said no. when asked whether they have done a regenerative endodontic procedure before for their patients, 77.4% said yes and 22.6% said no. When asked about the indication for the treatment by a regenerative endodontic procedure, 31% said root resorption, 48.8% said immature apex with necrotic, 11.9% said persistent periapical infection and 8.3% said periapical cyst resolution. When the reason for not practising regenerative endodontic procedure was asked, 52.4% said they don't have sufficient knowledge regarding regenerative endodontic procedure, 36.9% said they haven't encountered any case before and 10.7%they don't have sufficient training to perform the treatment. When asked about the assessment of regenerative dental treatment outcomes, 39.3% said successful, 42.9% said unsuccessful and 17.9% said they didn't know. When asked about the challenge faced during regenerative endodontic procedure, 23.8% said to obtain a sufficient number of autogenous cells, 39.3% said scaffolds, 22.6% said growth factors, 6% said unpredictable outcomes.

In a previous survey, A total of 311 (69.12%) dental practitioners of which 69.14% (n = 215) were male and 30.87% (n = 96) were female had appropriately filled the questionnaires [42]. In a previous survey, results showed that 96.8% of dentists are willing to receive training to be able to provide regenerative endodontic procedures for their patients. Of the total group, 49.1% of dentists already use membranes, scaffolds, or bioactive materials to provide dental treatment. It was determined that 47.3% of dentists agree that the costs of regenerative procedures should be comparable with current treatments. It was also found that 55.1% of dentists were unsure whether regenerative procedures would be successful [43]. In another survey, conducted by British Society of Paediatric Dentistry, the reasons for not using regenerative endodontic procedure was lack of training 45%, materials 26%, evidence 16% and suitable cases 6% [44]. In a previous survey, 66.2% of the respondents had not used any kind of regenerative procedures in their clinical practice, 54.3% were unaware of the treatment outcomes [45]. In a previous survey, 14.6% had used umbilical cord or other types of stem cell banking for themselves or a relative. But in our survey, the dental pulp stem cells were used. Two third of participants (74.6%) thought the greatest obstacle to a patient accepting REP's would be higher cost of treatment, (12%) thought it would be fear of stem cell therapy and the remaining (13.3%) thought it would be due to other reasons [19]. There are several sources of stem cells in the oral cavity with some researchers implicating stem cells of the apical papilla (SCAP) as having a major role in RET [46]. Lovelace et al., reported a 400–600-fold increase in mesenchymal stem cell markers in blood collected from the root canal [47]. In tissue engineering, a scaffold is an endogenous or transplanted material that provides a three - dimensional microenvironment promoting cell growth, differentiation, adhesion and migration [48]. Promoting a blood clot in RET has the advantage of transporting stem cells from the apical area into the root canal system whilst allowing these cells to differentiate in a three-dimensional manner. However, referring to a blood clot as a scaffold is controversial [49]. To disinfect the root canal system, minimal instrumentation of the canals was performed to prevent damage to the thin enamel walls followed by irrigation with 0.5% sodium hypochlorite and application of a bi-antibiotic paste containing 100 mg ciprofloxacin and 100 mg metronidazole to the root canal system [50].

Conclusion

Traditional root canal therapy of necrotic pulps is mechanically and materially based. Regenerative endodontic therapy is biologically based and intended to promote the host’s natural wound healing process to restore vitality, immunity, and sensitivity of tissue in the canal space that was destroyed by infection or trauma. In order to harness this potential, the dental practitioners need to be aware and well informed regarding the same. This will allow the introduction of a new era in clinical endodontic dentistry that will help in preserving the vitality of the tooth. In this survey, the dental practitioners and endodontists have knowledge regarding certain aspects of the regenerative endodontic procedures but they lack knowledge in practical aspects. Training regarding the same can be done so as to facilitate the incorporation of regenerative endodontics in dental clinics.

Acknowledgement

We thank Saveetha Dental College, Saveetha University, SIMATS for supporting us to conduct the study.

Source of Funding

This study was supported by the following agencies.

• Saveetha Dental College
• SIMATS, Saveetha University
• Virtusa Consultancy Services.