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Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intra-canal fracture of endodontic instruments. Part 2

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Aim To investigate the attitudes of general dental practitioners (GDPs) and endodontists in the UK towards management of fractured endodontic instruments.Methodology A questionnaire was sent to 330 systemically selected GDPs and all endodontists
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  Opinions and attitudes of endodontists and generaldental practitioners in the UK towards theintracanal fracture of endodontic instruments:part 1 A. A. Madarati, D. C. Watts & A. J. E. Qualtrough School of Dentistry, University of Manchester, Manchester, UK Abstract Madarati AA, Watts DC, Qualtrough AJE.  Opinions andattitudes of endodontists and general dental practitioners in theUK towards the intracanal fracture of endodontic instruments:part 1.  International Endodontic Journal  ,  41 , 693–701, 2008. Aim  To investigate the attitudes and opinions of general dental practitioners (GDPs) and endodontistsin the UK towards fracture of endodontic instruments.It was hypothesized that there would be no significantdifference between GDPs and endodontists regardingtheir experience of fracture of endodontic instruments. Methodology  A pilot questionnaire was carried outon 20 postgraduate dental students to ensure that thequestionswereeasilyunderstood.ThiswasfollowedbyafurtherpilotsurveyonagroupofGDPsandendodontists(50) to facilitate sample size calculation. The sample sizecomprised 330 systematically selected GDPs, and allendodontic specialists working in the UK (170). Thequestionnaire comprised both close-ended and partiallyclose-ended questions in four categories: demographics;pattern of practice and experience of instrument frac-ture; management of fractured instruments; and unsuc-cessful management of fractured instruments.Nonrespondents were sent another two mailings (firstand second reminders). After collecting the responses,data were analysed using chi-square and Linear-by-Linear Association tests at the 0.05 level of significance. Results  The overall response rate was 75% (82.82%for endodontists and 70.92% for GDPs). Overall, 88.8%of respondents had experienced fractured instrumentswith a significantly higher proportion of endodontists(94.8%) compared with that of GDPs (85.1%). Conclusion  Both endodontists and GDPs wereaware of most factors contributing to endodonticinstrument fracture. With experience and knowledge,fracture of endodontic instruments was associated withthe number of root canal treatments performed. Keywords:  endodontic files separation, instrumentsfracture, questionnaire, survey. Received 18 September 2007; accepted 11 March 2008 Introduction Fracture of endodontic instruments is a problematicincident that may occur during root canal preparation.Even with the advent of nickel–titanium (NiTi) instru-ments, which are reported to be stronger and moreflexible (Walia  et al.  1988); fracture still may occurespecially in canals that are narrow and curved(Hu¨lsmann & Schinkel 1999). Many studies haveinvestigated the occurrence and removal of fracturedinstruments and other associated factors (Hulsmann &Schinkel 1999, Shen  et al.  2004, Suter  et al.  2005).However, little information is available regarding theopinions and attitudes of dental practitioners inthis regard. Survey studies can provide informationabout the knowledge, attitudes, preferences, opinions, Correspondence: Ahmad Madarati, Endodontics postgraduate,School of Dentistry, University of Manchester, Higher Cam-bridge Street, Manchester, United Kingdom, M15 6FH (Tel.:+44 7917117213; fax: +44 161 275 6710; e-mail:ahmad.madarati@hotmail.co.uk).doi:10.1111/j.1365-2591.2008.01425.x ª  2008  International Endodontic Journal International Endodontic Journal ,  41 , 693–701, 2008  693  experiences, practices and demographics of participants(Fink 1995). Nevertheless, such studies should be wellplanned and conducted to enable a high response rateso that results will be representative (Lydeard 1991).In a study related to the integration of the Light-Speed rotary system (Lightspeed Technology Inc., SanAntonio, TX, USA) into dental practice in Switzerland,76% of participants reported that they had experi-enced fracture of rotary instruments (Barbakow & Lutz1997). Respondents reported various reasons forinstrument fracture such as excessive pressure, incor-rect insertion angle and complex anatomy. Anotherstudy evaluated the introduction of NiTi rotarysystems in dental practice in Australia and reported74% of participants had experienced fracture of rotaryinstruments (Parashos & Messer 2004).The aim of this study was to investigate the attitudesand opinions of general dental practitioners (GDPs) andendodontic specialists in the UK towards endodonticinstrument fracture. This article will cover the first twoparts of the study which are related to endodonticpractice and experience of instrument fracture. It washypothesized that there would be no significant differ-ence between GDPs and endodontists regarding theirexperience of fracture of endodontic instruments. Material and methods This study was granted Ethics Committee approval bythe Multi-Centre for Research Ethics Committee forWales. A pilot self-administrated questionnaire was firstcarried out on 20 postgraduate students at the School of Dentistry, University of Manchester to ensure that thequestions were easily understood. This was followedby a further pilot survey on a group of GDPs andendodontists to facilitate sample size calculation. Thesamplesizecomprised330systematicallyselectedGDPs,and all endodontic specialists working in the UK (170).The questionnaire comprised both close-ended andpartially close-ended questions in four categories: •  Demographics: five non-numbered questions (fourclosed-ended and one partially closed-ended). •  Pattern of practice and experience of instrumentsfracture: 17 questions (14 closed-ended and threepartially closed-ended). •  Management of fractured instruments: six questions(four closed-ended and two partially closed-ended). •  Unsuccessful management of fractured instruments:four closed-ended questions.The questionnaire was accompanied by a coveringletter signed by the main investigator. The coveringletter explained the aims and objectives of the studyand indicated that all information would remainconfidential and anonymous. Also it stated thatrespondents would be entered into a prize draw. Aprepaid envelope was included with the address of themain investigator. The prepaid envelope was returnedto the main researcher who only had access to the datacollection form number but not the sample list itself.After each mailing, a list of numbers of those whoresponded was given to a third person unrelated to thestudy and a new list prepared for the next mailing.Nonrespondents were sent another two mailings (firstand second reminders) comprising a differently wordedcovering letter; a prepaid envelope; and another copy of the questionnaire. After collecting the responses, datawere entered into SPSS 14 for Windows software (SPSSInc., Chicago, IL, USA). They were analysed using chi-square and Linear-by-Linear Association tests at the0.05 level of significance. Fifty (GDPs and endodontists)who completely responded to the questionnaire wererandomly allocated 50 prizes (monetary and dentalsamples). Results Response rate details Practitioners or responses included in the surveysample were divided into three groups as follows: •  Usable responses: included respondents who partially(CP) or completely (CC) completed the questionnaire. •  Nonrespondents: included those who did not respondto the study or returned blank copies. •  Ineligible sample: included those who changedaddress; had addresses outside of the UK; were retired;did not perform root canal treatment (RCT); or wereregistered in other specialities.The completion (initial) response rate was as follows: •  Overall initial response rate: 357/500 = 71.4%. •  General dental practitioners initial response rate:222/330 = 67.27%. •  Endodontists initial response rate: 135/170 = 79.4%.Of the srcinal sample size (500) and according tothe criteria described above, 24 (17 GDPs and sevenendodontists) proved to be ineligible. One GDP refusedto participate and returned a blank questionnaire.Ineligible cases were not considered when the finalresponse rate was calculated (Locker 2000, Parashos &Messer 2004). Thus, the response rate achieved in thissurvey study was as follows: Endodontic files fracture survey  Madarati et al. International Endodontic Journal ,  41 , 693–701, 2008  ª  2008  International Endodontic Journal 694  •  Total sample size: 500 ) 24 = 476 (overall responserate of: 357/476 = 75%). •  General dental practitioners sample size: 330 ) 17 =313 (response rate of: 222/313 = 70.92%). •  Endodontists sample size: 170 ) 7 = 163 (responserate of: 135/163 = 82.82%). Year of graduation The year of graduation ranged from 1955 to 2006(Table 1). The proportion of GDPs graduating between1997 and 2006 (27.5%) was significantly higherthan that of endodontists (5.9%). Nevertheless, therewere no significant differences between the fourgroups of year of graduation for all respondentsregarding their experience of instrument fracture( v 2 = 5.93, d.f. = 3,  P  = 0.204). The results did notshow linear correlation between practice experience(years after graduation) and experience of instrumentfracture either within the whole sample (Linear-by-Linear Association = 2.78, d.f. = 1,  P  = 0.095) orwithin both groups of GDPs ( P  = 0.242) and end-odontists ( P  = 0.577). Patterns of work Most respondents (65%) worked in private practice(Table 2). The proportion of respondents who workedin private practice and had experienced instrumentfracture (96.6%) was significantly higher than theproportion of those who had experienced instrumentfracture but did not work privately (75%) ( v 2 = 38.48,d.f. = 1,  P <  0.001). The majority of endodontists(75.6%) worked in private practice and this wassignificantly higher than that of GDPs (58.8%)( v 2 = 10.33, d.f. = 1,  P  = 0.01). Number of cases per week Whilst the highest proportion of endodontistsperformed more than 10 cases per week (45.9%),the lowest proportion of GDPs did so (4.5%) (Table 3).Experience of instrument fracture was positively cor-related with the number of endodontic cases per-formed per week (Linear-by-Linear Association =24.81, d.f. = 1,  P <  0.001). Thus, experience of instrument fracture significantly increased as thenumber of endodontic cases performed per weekincreased. This was applied to both groups of GDPsand endodontists. Use of hand instruments Overall, 64.1% of respondents used stainless steel (SS)hand instruments (Table 4). The proportion of end-odontists who used SS hand instruments (80%) wassignificantly higher compared with that of GDPs Table 1  Respondents details regarding year of graduation Range GDPs Endodontists Total1997–2006 27.5% (80.3) 5.9% (87.5) 19.3% (81.2)1987–1996 20.7% (82.6) 34.8% (95.9) 26.1% (89.2) a 1977–1986 27.5% (91.8) 37.8% (94.1) 31.4% (92.9)Before 1977 24.3% (85.2) 21.5% (96.6) 23.2% (89.2)Total 100% (85.1) 100% (94.8) 100% (88.8)The values in the brackets represent proportion of respondentswho experienced fracture of endodontic instruments. a Significantly more endodontists experienced SEF than GDPs.GDPs, general dental practitioners. Table 2  Respondents details for work patterns (multipleanswers were available) PatternsEndodontists(%)GDPs(%)TotalWork Do not workPrivate practice 75.6 58.8 65.2% (96.6) 34.8% (75) a NHS 22.2 71.9 53.1% (84.7) 46.9% (94) a University 32.6 9 18% (89.1) 82% (89)The values in the brackets represent proportion of those respon-dents who experienced fracture of endodontic instruments. a A significant difference in experience of fracture of endodonticinstruments between those who work and those who do not.GDPs, general dental practitioners. Table 3  Number of root canal treat-ments performed per week Respondents1–2cases3–5cases6–10casesMore than10 cases TotalGDPs 36.9% (74.4) 45.9% (89.2) 12.6% (100) 4.5% (90) 100% (85.1)Endodontists 23.7% (81.3) 15.6% (100) 14.8% (95) 45.9% (100) 100% (94.8)Total 31.9% (76.3) 34.5% (91.1) 13.4% (97.9) 20.2% (98.6) 100% (88.8)The values in the brackets represent proportion of respondents who experienced SEF.A significant difference was found between endodontists and GDPs in all categoriesexcept in those who perform 6–10 cases.GDPs, general dental practitioners. Madarati et al.  Endodontic files fracture survey ª  2008  International Endodontic Journal International Endodontic Journal ,  41 , 693–701, 2008  695  (54.5%) ( v 2 = 23.73, d.f. = 1,  P <  0.001). Neverthe-less there was no significant difference between end-odontists and GDPs regarding the use of NiTi handinstruments with overall use being 65.5% ( v 2 = 1.6,d.f. = 1,  P  = 0.205). A total of 108 (30.3%) of respondents used both SS and NiTi hand instruments.A significantly higher proportion of endodontists(49.6%) used both hand instruments compared withthe proportion of GDPs (18.5%) ( v 2 = 38.63, d.f. = 1, P <  0.001). Use of rotary systems A total of 271 (75.9%) of respondents used rotarysystems for root canal preparation. The vast majority of endodontists used rotary systems (92.6%) and this wassignificantly higher than that reported by GDPs (65%)( v 2 = 33.039, d.f. = 1,  P <  0.001). Table 5 shows thethree most common rotary systems used by therespondents. The proportion of endodontists usingProTaper (Dentsply Ltd, Surrey, UK) (81.6%) wassignificantly higher than that of GDPs (39.7%)( v 2 = 48.829, d.f. = 1,  P <  0.001); 68 (25.1%) of respondents use (or used) more than one rotary system.A significantly higher proportion of endodontists (32%)used more than one rotary system compared with thatof GDPs (19.2%) ( v 2 = 5.890, d.f. = 1,  P  = 0.015). Hands-on courses A total of 283 (79.3%) of respondents had attendedhands-on training courses. A significantly higherproportion of endodontists (89.6%) had attendedcourses compared with GDPs (73%) ( v 2 = 14.175,d.f. = 1,  P <  0.001). Moreover, the proportion of endodontists attending more than six courses (35%)was significantly greater than that of GDPs (10.4%)( v 2 = 34.068, d.f. = 2,  P <  0.001). Instrument examination Participants were asked when they usually examineinstruments. Answers were categorized into six closed-ended responses (Table 6). The majority of respondents(77%) indicated that they examined instruments  beforetreatment . The proportion of endodontists doing so(84.4%) was significantly higher than that of GDPs(72.5%) ( v 2 = 6.744, d.f. = 1,  P  = 0.009); 67.8% of respondents used to examine instruments  regularly during treatment. A significantly higher proportion of endodontists (88.1%) examined instruments regularlyduring treatment compared with GDPs (55.4%)( v 2 = 41.217, d.f. = 1,  P <  0.001). Results showedthat 184 (55.3%) of respondents examine endodonticinstruments both before and regularly during endodon-tic treatment. The proportion of endodontists followingthis combined pattern of instrument examination(75.2%) was significantly higher than that of GDPs(42%) ( v 2 = 35.586, d.f. = 1,  P <  0.001). Use of magnification for instrument examination The question regarding the use of magnification toexamine endodontic instruments had three answers Table 4  Types and patterns of hand files use (multipleanswers were available) Respondents SS files (%) NiTi files (%)Combineusage (%)GDPs 54.5 63.1 18.5Endodontists 80 69.6 49.6Total 64.1 a 65.5 30.3 aa A significant difference was found between endodontists andGDPs.SS, stainless steel.GDPs, general dental practitioners.NiTi, nickel–titanium. Table 5  Details of respondents for use of rotary systems Patterns androtary systems usedGDPs(%)Endodontists(%)Total(%)At least one rotary system 65.8 92.6 75.9 a Multiple use 19.2 32 25.1 a ProTaper 39.72 81.6 59.04 a ProFile 35.37 25.6 30.99K3 17.68 12 15.12 a A significant difference was found between endodontists andGDPs.GDPs, general dental practitioners. Table 6  Patterns of endodontic files examination (multipleanswers were available) PatternsEndodontists(%)GDPs(%)Total(%)Before treatment 84.4 72.5 77Regularly during treatment 88.1 55.4 67.8After treatment 45.9 27 34.2Occasionally during treatment 6.7 23.9 17.4Before sterilization 11.9 5.9 8.1After sterilization 6.7 4.1 5Both before and during regularly 75.2 42 55.3A significant difference was found between endodontists andGDPs in all patterns except after file sterilization.GDPs, general dental practitioners. Endodontic files fracture survey  Madarati et al. International Endodontic Journal ,  41 , 693–701, 2008  ª  2008  International Endodontic Journal 696  (always, sometimes and never). Overall, 36.8% of respondents  always  use magnification to examineinstruments. A significantly higher proportion of end-odontists (63.4%)  always  use magnification comparedwith GDPs (20.7%) ( v 2 = 93.869, d.f. = 2,  P <  0.001).The overall proportion of respondents who  sometimes use magnification was (23.6%) with no significantdifference between endodontists and GDPs. Pattern of instrument discard In total 252 (70.6%) of respondents discarded end-odontic instruments after a certain number of uses andthis was the most common pattern (Table 7). The vastmajority of endodontists (94.1%) discarded instru-ments after a certain number of uses and this wassignificantly higher than the proportion of GDPs(56.3%) ( v 2 = 57.67, d.f. = 1,  P <  0.001); 113(44.8%) of respondents discarded instruments aftersingle use with a significant higher proportion of endodontists (57.5%) compared with that of GDPs(32%) doing so ( v 2 = 16.54, d.f. = 1,  P <  0.001).Only 52 (20.6%) of respondents discarded instrumentsafter six or more times of use with a significantlyhigher proportion of GDPs (27.2%) compared withthat of endodontists (14.2%) ( v 2 = 6.528, d.f. = 1, P  = 0.011). Although only 27.2% of all respondentsdiscarded used instruments after observing defects bymagnification, a reasonable proportion of endodontists(40%) adopted this pattern of instrument discard andthis was significantly higher than that of GDPs(19.4%) ( v 2 = 18.05, d.f. = 1,  P <  0.001). Factors contributing to instrument fracture Factors considered to contribute to fracture of end-odontic instruments were categorized into five groups.Respondents were asked to rank groups of factors fromthe most important as one to the least important as five.Overall there was an agreement between endodontistsand GDPs. Factors related to the operator (i.e. experi-ence, frequency of instruments usage) were consideredas the most significant aspects that contribute toendodontic instrument fracture (54.6%). The secondwere factors related to root canal anatomy (i.e. canalsize, curvature) (49%). However, factors related to themanufacturers (i.e. method and conditions of manu-facturing) and the environment (i.e. irrigants, instru-ments sterilization) were considered as the leastimportant (fourth and fifth respectively). Factors relatedto instrument design were considered of moderateimportance (third). Experience of instrument fracture A key question in the survey asked whether or notparticipants had experienced endodontic instrumentsfracture. In case of an affirmative answer, respondentswere asked two further questions to specify what type of instruments (hand or rotary) were involved (multipleresponses were available). A total of 317 (88.8%) of respondents had experienced fracture of endodonticinstruments (Table 8). A significantly higher proportionof endodontists (94.8%) had experienced instrumentfracture compared with GDPs (85.1%) ( v 2 = 7.906,d.f. = 1,  P  = 0.005). Of the 317 respondents who hadexperienced instrument fracture, 237 (74.76%) hadexperienced fracture of hand instruments. There was nosignificant difference between endodontists and GDPs(73.43% and 75.66% respectively) ( v 2 = 1.023,d.f. = 1,  P  = 0.312). Table 7  Pattern of endodontic file discard (multiple answerswere available) PatternsEndodontists(%)GDPs(%)Total(%)After certain number of use 94.1 56.3 70.6After naked-eye defects 32.6 64.9 52.7After magnified defects 40 19.4 27.2Other patterns 8.1 1.4 3.9After single use 57.5 32 44.8After 2–5 times of use 26.8 40 33.3After 6 or more times of use 14.2 27.2 20.6A significant difference was found between endodontists andGDPs in all patterns.GDPs, general dental practitioners. Table 8  Respondents details regarding their experience of file’s separation (multiple answers were available) Fileseparation Endodontists GDPs TotalExperience of files fracture128 (94.8%) 189 (85.1%) 317 (88.8%) a Experience of hand files fracture94 (73.4%) 143 (75.7%) 237 (74.8%)Experience of rotary file fracture119 (92.96%) 124 (65.6%) 243 (76.7%) a Experience of rotary files fracturewithin rotarysystems users117 (93.6%) 116 (79.5%) 233 (85.97%) aa A significant difference was found between endodontists andGDPs.GDPs, general dental practitioners. Madarati et al.  Endodontic files fracture survey ª  2008  International Endodontic Journal International Endodontic Journal ,  41 , 693–701, 2008  697
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