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Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 96-101

Knowledge and attitude of pediatric dentists, general dentists, postgraduates of pediatric dentistry, and dentists of other specialties toward the endodontic treatment of primary teeth

Department of Pedodontics and Preventive Dentistry, Terna Dental College, Navi Mumbai, Maharashtra, India

Date of Web Publication16-Dec-2016

Correspondence Address:
Dr. A Farhin Katge
Department of Pedodontics and Preventive Dentistry, Terna Dental College, Sector 22, Plot No. 12, Nerul (W), Navi Mumbai - 400 706, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-8844.195917

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Background: Pediatric dentists (PDs) play an important role in treating primary teeth and oral health care needs for children. Pulp therapy is widely used in the treatment of primary teeth. The choice of endodontic treatment modality changes among general dentist (GD) and PD. Aim and Objectives: The aim of this study is to determine the attitudes of PDs, GDs, postgraduates (PGs) of pediatric dentistry and dentists of other specialties toward endodontic treatment of primary teeth. Materials and Methods: A structured 20-item questionnaire was formulated in English and distributed to PD, GD's, PGs of pediatric dentistry, and dentist of other specialties. The filled questionnaire survey was statistically analyzed using simple descriptive analysis and inferential analysis was performed using Chi-square t- test. Results: Out of the 237 survey respondents, 27.43% were BDS (GD's), 16.88% were MDS (PD), 12.66% were PG's (pediatric dentistry), and 43.04% were MDS (other than PD). About 91.6% of the total respondents preferred endodontic procedures in primary teeth. Conclusion: The study concluded that the GD's, PD's, and dentist of other specialty differ in their treatment recommendations for primary teeth. The GDs and dentist of other specialty were regularly performing pulp therapy in primary teeth and should frequently update their knowledge about endodontic procedures in primary teeth.

Keywords: Endodontic treatment, general dentist, pediatric dentist, postgraduates, primary teeth, professional attitude

How to cite this article:
Patil P D, Katge A F, Rusawat D B. Knowledge and attitude of pediatric dentists, general dentists, postgraduates of pediatric dentistry, and dentists of other specialties toward the endodontic treatment of primary teeth. J Orofac Sci 2016;8:96-101

How to cite this URL:
Patil P D, Katge A F, Rusawat D B. Knowledge and attitude of pediatric dentists, general dentists, postgraduates of pediatric dentistry, and dentists of other specialties toward the endodontic treatment of primary teeth. J Orofac Sci [serial online] 2016 [cited 2022 Jan 23];8:96-101. Available from:

  Introduction Top

Pediatric dentistry is related to consider the child's feelings, to gain the child's confidence, and co-operation to perform the desired treatment in a kind manner. Pediatric dentist (PD) also plays an important role in promoting child's future dental health by stimulating the attitude and behavior regarding dental care.

Children and young adults often develop deep carious lesions due to the poor oral hygiene and inadequate dental care. These carious lesions if left untreated lead to deeper carious lesions eventually involving the pulp.[1] Despite the modern advances in prevention of dental caries and an increased understanding of the importance of maintaining the natural dentition, many teeth are still lost prematurely. The preservation of an intact primary tooth until eruption of the permanent successors is very important in maintaining the integrity of the arch form.[2] Pulpotomy and pulpectomy are widely used pulp therapy procedures in the treatment of carious primary teeth, while attempting to prevent premature exfoliation of the primary teeth. The main objective of endodontic treatment is total elimination of microorganisms from the root canal and the prevention of subsequent reinfection.[3]

One of the challenging aspects in pediatric dentistry is endodontic therapy in primary tooth. Diagnosis of pulp pathology and deciding the correct treatment plan are the key factors for successful endodontic treatment in primary teeth. Other factors such as instrumentation technique, obturating materials, irrigants, root canal morphology, root resorption, and follow-up period also plays an important role in deciding whether the endodontic treatment is successful or not. Fear of damage to developing permanent tooth buds and a belief that the tortuous root canals of primary teeth could not be adequately negotiated, cleaned, shaped, and filled have led to the needless sacrifice of many pulpally involved primary teeth. Many a times, the treatment done remains incomplete either due to the lack of knowledge of the dentist or due to noncooperation on the part of the child.[3] Because of such factors many dental practitioner prefer extraction as the desired treatment option for pulpally involved primary teeth. Premature extraction of primary teeth may cause aberration of the arch length, resulting in mesial drift of the permanent teeth and consequent malocclusion. Whenever possible, the tooth with pulp involvement should be maintained within the dental arch in a functional and disease-free condition.[4]

The question arises, is there a difference between PD's, general dentist's (GD's), and dentist of other specialty regarding treatment approach for endodontics in pediatric patients? Numerous studies investigated the attitude of dentists in western countries such as the UK, USA, European countries, and also gulf countries such as Saudi Arabia.[3],[5],[6],[7] Very few studies have investigated the attitude of general dental practitioners toward various aspects of endodontic treatment in primary teeth in developing countries like India. Hence, the aim of this survey was to determine the attitudes of PDs, GDs, postgraduates (PGs) of pediatric dentistry and dentist of other specialties toward endodontic treatment of primary teeth.

  Materials and Methods Top

Approval from the Institutional Ethical Review Board was obtained before commencement of this survey. The survey was conducted in five different dental institutes in Mumbai region. Two teams of two assistants were formed to carry out the distribution and collection of the survey forms from different dental institutes.

A structured 20-item questionnaire was formulated in English to determine the variables associated with the attitude of dentists towards endodontic therapy in primary teeth. Pilot study was conducted among 50 dentists to check the appropriateness of the questionnaire and it was found that the questions were unambiguous clear and easy to respond. Questionnaire was distributed to PD's, GD's, PG's, and dentists of other specialties. After explaining the purpose of the study, they were requested to complete the questionnaire and submit. Questionnaire was designed with the initial part of the questionnaire seeking personal details such as qualification, gender, and age range. Second part of questionnaire was based on endodontic approach, materials and methods used in the endodontic procedure in primary teeth. In the second part, two case scenarios were presented to the respondents and were asked to choose the most preferred option for the same. Each case contained a radiograph of a decayed primary molar and a written clinical description.

Data were analyzed using MedCalc Statistical Software version 12.7.2 (MedCalc Software bvba, Ostend, Belgium). Frequency and percentage distribution were calculated. Simple descriptive statistics were used combine with Chi-square t-test. Statistical significance for all tests was accepted at P < 0.05. Blank or multiple answers were all treated as missing values, only single unequivocal replies were included in calculating frequencies and percentages.

  Results Top

A total of 237 survey questionnaires were distributed. All 237 questionnaires were filled and returned with the response rate of 100%. Out of the total survey respondents, 40 were PD's (16.88%), 65 were GD's (27.43%), 30 were PG's (12.66%), and 102 were dentist of other specialties (43.04%). Among all 237 respondents, 116 were male and 121 were female. When asked about their age, 70.5% (167/237) of the respondents were from 25 to 35 age group, 22.4% (53/237) were from 35 to 45 age group, 4.6% (11/237) were from 45 to 55 age group, 2.5% (6/237) were from 55 and above age group. The dentists were asked about the preference of endodontic treatment in primary teeth. About 92% (217/237) of the total respondents preferred to do endodontic treatment in pediatric patients in which 23.2% were GD's, 16.0% were PD's, 12.7% were PG's, and 39.7% were dentists from other specialties [Figure 1]. For case 1, a radiograph [Figure 2]a and the following clinical scenario were presented:
Figure 1: Preference of endodontic practice

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Figure 2: (a) Intraoral periapical radiograph of 74, 75 and 36 (case scenario 1). (b) Intraoral periapical radiograph of 75 (case scenario 2)

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Peruse the radiograph: A 7-year-old-child present with painful 74, 75, and 36 with vestibular tenderness (36 is erupting). Your diagnosis in third quadrant would be?

121/237 of the respondents selected interradicular pathology with 74 (51%) as the most preferred diagnosis, in which 21% (25/121) were PD's, 26% (32/121) were GD's, 18% (22/121) were PG's, and 26% (32/121) were dentists from other specialty. Other diagnostic options were operculitis (18.6%), no dental pathology (17.7%), and interradicular pathology with 75 (7.2%) [Table 1].
Table 1: Case scenario 1: Diagnostic preferences among respondents

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For case 2, a radiograph [Figure 2]b and the following clinical scenario were presented: Peruse the radiograph: A 6-year-old cooperative child diagnosed as periapical abscess in left primary mandibular molar (75) which is asymptomatic. Decide suitable treatment option? The most preferred treatment option was extraction with space maintainer (53.6%) followed by standard endodontic treatment (37.6%), extraction and observation for successor to erupt (8.0%). Observation as it is asymptomatic (0.8%) was the least preferred options among respondents [Table 2].
Table 2: Case scenario 2: Treatment preferences among respondents

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About 41.6% (96/237) of the total respondents considered “Difficulty in behavior management” as the common reason for rejecting endodontic treatment in primary molars. Other reasons were “poor efforts to cost ratio/more efforts: Low cost of treatment ratio (10%) and unable to locate canals due to complex root canal anatomy (8.7%).” 39.8% considered “All of the above” as the common reason for rejecting endodontic treatment [Figure 3].
Figure 3: Common reason for rejecting endodontic treatment in primary molars

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For pain control method before endodontic treatment of primary mandibular molar, respondent considered standard inferioralveolar (IA) nerve block (41.8%) as the appropriate method followed by use of pulp devitalizing agents (26.2%), intra pulpal anesthesia (22.4%). About 2.5% of the respondents choose not to use of local anesthesia generally considering primary teeth as nonvital teeth. Working length radiograph (41.8%) and tentative working length using pretreatment radiograph (31.2%) were the two common methods used for working length determination by the respondents. Use of apex locator (13.5%) for working length was considered less.

Nearly 64.3% of respondents did not prefer to use rubber dam for isolation in pulp therapy procedures in children. About 51.1% of the survey respondents selected K-file as the choice of endodontic file for root canal debridement in primary molars. Rotary instrumentation was not preferred as instrumentation technique in endodontic procedure in primary molar (69.2%). Zinc oxide eugenol (46.7%) and calcium hydroxide iodoform paste (35.8%) was the materials preferred for obturation in deciduous teeth by the respondents [Figure 4]. The most frequently used obturation technique was the use of handheld reamers (32%) followed by obturation syringes (30%). However, slow-speed lentulospirals (18%) were used by very few dentists. When asked about the effect of inadvertent extrusion of zinc oxide eugenol in periapical region (beyond apex), 53.6% of respondents said there will be no problem as it is a resorbing material, whereas 20.2% said there will be delayed eruption of permanent successors. Others (18.5%) thought it may injure the underlying permanent tooth germ. The final restoration preferred for endodontically treated primary tooth was stainless steel crown (37.6%), 36.3% used glass ionomer cement (GIC), 2.7% used composite and silver amalgam showed least preference (11.8%). 73.7% of respondents preferred to take postendodontic treatment X-ray in pediatric patient.
Figure 4: Preference for obturating material

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  Discussion Top

The indications, objectives, and type of pulpal therapy depend on whether the pulp is vital or nonvital. It also depends on clinical diagnosis of normal pulp (symptom free and normally responsive to vitality testing), reversible pulpitis (pulp is capable of healing), symptomatic or asymptomatic irreversible pulpitis (vital inflamed pulp is incapable of healing), or necrotic pulp.[3] Pulpectomy since long has created a dilemma in the view of the clinician owing to the tortuosity of the canals of a primary molar. Meticulous biomechanical preparation determines the success or outcome of root canal treatment in permanent teeth; however, the resorbable nature and antimicrobial properties of the filling material determine the success of pulpectomy in a primary tooth. Preparation of the root canal in a primary tooth is based mainly on chemical means rather than mechanical debridement. Zinc oxide eugenol is the most commonly used material for pulpectomy of the primary teeth.[8],[9]

In this study, we were interested in knowing the obturation material and the technique that dentist's favored for primary teeth. 92% preferred to do endodontic treatment in primary teeth. When the case scenarios were presented to the respondents, in both the scenarios majority of respondents selected right treatment plan and diagnose the right condition. This reflects the awareness among the dental practitioner about maintaining the primary tooth in dental arch. They are also aware about importance of space loss in dental arch and focus more toward preventive orthodontics in pediatric patient.

Our results were not in agreement with studies by Togoo et al.,[3] McKnight-Hanes et al.[10] and Bowen et al.[6] Togoo et al. in 2012 and McKnight-Hanes et al. in 1991 observed that the GDs and PD differ in their treatment recommendations. Bowen et al.[6] assessed and compared the attitudes of pediatric and GDs regarding treatment planning of indirect pulp therapy in primary teeth. They concluded that there were significant differences between pediatric and GDs in terms of treatment planning in primary teeth.

The common reason for rejecting endodontic treatment in primary molars was difficulty in behavior management (41.6%). 39.8% thought that difficulty in behavior management and poor efforts to cost ratio are the reasons for rejecting treatment in pediatric patient. This results were supported by the survey conducted by Halawany et al.[11] suggested that majority of private practitioners have a positive attitude toward treating children, but time consumption and financial loss were found to be a major barrier in treating children and those with special health care needs effectively.

The most common technique to anesthetize mandibular primary teeth is IA nerve block injection which induces a relatively sustained anesthesia and in turn, may potentially traumatize soft tissues.[12] Similar technique was selected to anesthetize primary mandibular molar by the respondents in our study. This study revealed that use of apex locator (13.5%) was less and radiographic technique (41.8%) was more for working length determination. Due to the limitations of radiographic interpretation and high possibility of over-instrumentation of the unevenly resorbed roots and subsequent overfilling, the application of electronic apex locators is recommended regardless of the stage of root resorption.[13],[14] Results reported very less use of rubber dam for isolation but according to American Academy of Pediatric Dentistry [15] and the UK National Clinical Guidelines [16] for pulp treatment in the primary dentition the application of the rubber dam is mandatory.

Our survey showed less preference for rotary instrument during pulpectomy procedure. K-files were selected as files used for pulp debridement. Ahmed [13] suggested during chemo-mechanical preparation, stainless steel hand files usually not larger than size 30 should be used carefully to prevent the occasion of broken segments. Flexible files are recommended in curved and S-shaped canals. Rotary NiTi files can significantly reduce the instrumentation time of the primary root canals. Zinc oxide eugenol is the most commonly used material for pulpectomy of the primary teeth, but success rate with the material is very less as compared to other obturating material. Zinc oxide eugenol does not meet all criteria required for an ideal root canal filling material.[9] Coll and Sadrian [17] reported delayed resorption of extruded material, deflected or ectopic eruption of succedaneous tooth, anterior crossbite, and palatal eruption following zinc oxide eugenol pulpectomy. Ease of availability is the main reason for selection of zinc oxide eugenol. Therefore, the use of zinc oxide eugenol may be acceptable, but the use of commercially available pastes such as Metapex and Vitapex should be encouraged as both show higher success rates in the long-term follow-up studies.[18]

The most frequently used obturation technique was the use of handheld reamers followed by obturation syringes. However, slow-speed lentulospirals were used by very few dentists. As far as the quality of obturation and success rate of the treatment done is concerned, no statistically significant difference was observed between the use of a lentulo spiral mounted in a slow speed handpiece or hand held. Whereas optimally filled and overfilled root canals showed a statistically higher success rate compared to underfilled root canals.[19] Stainless steel crowns may be the best choice for restoration of endodontically treated deciduous teeth. The relatively minimal use of stainless steel crowns may be due to the lack of expertise among GDs. GIC and composite may have been used due to the ease of use and easy availability.[3],[20]

  Conclusion Top

From the present survey following conclusions can be drawn:

  • PDs are up to date about the newer techniques and materials used in the field of pediatric endodontics
  • The GDs and other specialty practitioners routinely perform pulp therapy in primary teeth
  • This study emphasizes the need for frequent update about endodontic procedures in pediatric patients among dental practitioners.

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Conflicts of interest

There are no conflicts of interest.

  References Top

McDonald RE, Avery DR, Dean JA. Treatment of deep caries, vital pulp exposure and pulpless teeth. In: McDonald RE, Avery DR, Dean JA, editors. Dentistry for the Child and Adolescent. 8th ed. St. Louis: Mosby Elsevier; 2007. p. 396.  Back to cited text no. 1
Waterhouse PJ, Whitworth JM, Camp JH, Fuks AB. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Hargreaves KM, Cohen S, editors. Cohen's Pathways of the Pulp. 10th ed. St. Louis: Mosby Elsevier; 2011. p. 809.  Back to cited text no. 2
Togoo R, Nasim V, Zakirulla M, Yaseen S. Knowledge and practice of pulp therapy in deciduous teeth among general dental practitioners in Saudi Arabia. Ann Med Health Sci Res 2012;2:119-23.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
Fuks AB. Pulp therapy of the primary dentition. In: Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW, Nowak AJ, editors. Pediatric Dentistry: Infancy through Adolscence. 4th ed. Philadelphia: Elsevier Saunders Inc.; 2010. p. 577-8.  Back to cited text no. 4
Foley JI. Management of carious primary molar teeth by UK postgraduates in paediatric dentistry. Eur Arch Paediatr Dent 2010;11:294-7.  Back to cited text no. 5
Bowen JL, Mathu-Muju KR, Nash DA, Chance KB, Bush HM, Li HF. Pediatric and general dentists' attitudes toward pulp therapy for primary teeth. Pediatr Dent 2012;34:210-5.  Back to cited text no. 6
Foley JI. Short communication: A pan-European comparison of the management of carious primary molar teeth by postgraduates in paediatric dentistry. Eur Arch Paediatr Dent 2012;13:41-6.  Back to cited text no. 7
Primosch RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States. Pediatr Dent 1997;19:118-22.  Back to cited text no. 8
Rewal N, Thakur AS, Sachdev V, Mahajan N. Comparison of endoflas and zinc oxide eugenol as root canal filling materials in primary dentition. J Indian Soc Pedod Prev Dent 2014;32:317-21.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
McKnight-Hanes C, Myers DR, Dushku JC, Barenie JT. A comparison of general dentists' and pediatric dentists' treatment recommendations for primary teeth. Pediatr Dent 1991;13:344-8.  Back to cited text no. 10
Halawany HS, Al-Fadda SA, Al-Saeed BH, Al-Homaied MA. The attitude of private dental practitioners towards treatment and management of children in Riyadh, Saudi Arabia. J Pak Dent Assoc 2011;20:245-9.  Back to cited text no. 11
Tudeshchoie DG, Rozbahany NA, Hajiahmadi M, Jabarifar E. Comparison of the efficacy of two anesthetic techniques of mandibular primary first molar: A randomized clinical trial. Dent Res J (Isfahan) 2013;10:620-3.  Back to cited text no. 12
Ahmed HM. Pulpectomy procedures in primary molar teeth. European J Gen Dent 2014;3:3-10.  Back to cited text no. 13
Ahmed HM. Anatomical challenges, electronic working length determination and current developments in root canal preparation of primary molar teeth. Int Endod J 2013;46:1011-22.  Back to cited text no. 14
AAPD. Guideline on pulp therapy for primary and immature permanent teeth. Pediatr Dent 2012;34:222-9.  Back to cited text no. 15
Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA; British Society of Paediatric Dentistry. Pulp therapy for primary molars. Int J Paediatr Dent 2006;16 Suppl 1:15-23.  Back to cited text no. 16
Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent 1996;18:57-63.  Back to cited text no. 17
Trairatvorakul C, Chunlasikaiwan S. Success of pulpectomy with zinc oxide-eugenol vs calcium hydroxide/iodoform paste in primary molars: A clinical study. Pediatr Dent 2008;30:303-8.  Back to cited text no. 18
Bawazir OA, Salama FS. Clinical evaluation of root canal obturation methods in primary teeth. Pediatr Dent 2006;28:39-47.  Back to cited text no. 19
American Academy of Pediatric Dentistry. Clinical Affairs Committee – Restorative Dentistry Subcommittee. Guideline on pediatric restorative dentistry. Pediatr Dent 2012;34:173-80.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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