An investigation into security, self-confidence and gender differences related to undergraduate education in Endodontics

AIM

To analyse responses from dental practitioners (DPs) on how secure they felt as a newly graduated dentist, level of confidence or self-efficacy when performing root canal treatment (RCT), and if undergraduate (UG) education in Endodontics adequately met their needs in a dental practice.

METHODOLOGY

An electronic questionnaire was sent to 459 dentists who graduated from the University of Bergen, Bergen, Norway, between 2008 and 2018. The survey consisted of questions with closed-end options and Likert scale (1-5). An open-ended free text option was always provided.

RESULTS

A total of 314 (68.4%) DPs answered the questionnaire. Of these, 87 (27.8%) were men and 224 (71.3%) were women. Three respondents did not disclose their gender. As a newly graduated dentist, 37.3% of the respondents felt secure when performing RCT, 30.7% felt indifferent, and 32.0% felt insecure. The majority (72.4%) of respondents were either confident or very confident when performing RCT, 21.3% were indifferent, and 6.3% had little or no confidence. A majority of DPs (84.4%) self-evaluated the quality of their root fillings as good or very good, and 15.2% were indifferent. Only one DP selected 'not good' and none selected 'bad'. There were significant gender differences where male DPs felt more secure than female DPs when performing RCT (P < 0.001). A significantly larger number of men were very confident compared to women (P < 0.001). A logistic regression analysis using confidence as a dependent variable to predict self-efficacy revealed that DPs who felt secure when performing RCT as a newly graduated dentist had about 8 times more self-efficacy (odds ratio = 8.49) than those who were insecure or indifferent. Respondents who rated their quality of root fillings as good or very good had forty times more self-efficacy (odds ratio = 40.06) when performing RCT. UG education in endodontics was considered inadequate by 71.3% of the respondents where a significantly larger number of DPs (70%) wanted more clinical training (P < 0.05). About half the DPs (47.7%) stated that there was a need for lifelong learning with majority preferring hands-on courses and continuing dental education organized by dental associations.

CONCLUSIONS

The results of this study suggest that there is a need to promote self-efficacy during UG education in Endodontics. Hands-on training is the preferred form of lifelong learning for DPs.

Instrument fracture in root canals - where, why, when and what? A study from a student clinic

AIM

To investigate the incidence of instrument fracture during nonsurgical root canal treatment performed by undergraduate dental students and to assess the outcome of the treatment if the remaining fragment was left or removed from the root canal.

METHODOLOGY

A retrospective analysis was performed by reviewing assessment forms (n = 3854) filled out for each root canal treatment over a 10-year period (1997-2006) at the University of Bergen, Norway. Based on the assessment forms, all instrument fractures and data concerning type and dimension of the fractured instruments were identified. Moreover, the affected tooth, root, root curvature and the vertical level of the fragment in the root canal were recorded. To assess the outcome of the root canal treatment, radiographs taken at follow-ups were evaluated by two individual examiners.

RESULTS

The overall incidence of instrument fracture during the period was 1.0% on a tooth level. Instrument fracture occurred significantly more often in molars and in teeth rated as difficult preoperatively. Of all instrument fractures, 39.5% were located in the mesio-buccal canals of molars, and 76.5% of the fragments were located apically. A significant high percentage of instruments of small apical diameter (sizes 006-015) fractured in relative straight root canals. The treatment was successful in 71.4% of the cases where the instrument fragment was removed, but only in 56.5% of the cases where the fragment remained in the root canal. Significantly more instruments were removed from teeth with a primary infection (P ≤ 0.05). The success rate for teeth with instrument fracture was 72.7% for vital teeth, 58.3% for primary infected teeth and 42.9% in retreatment cases.

CONCLUSIONS

Within the limits of the present study, the results indicate that the preoperative diagnosis is important for the final treatment outcome and that removal of the fragment is important in cases with primary infection.

Sociodemographic and behavioural correlates of severe dental fluorosis

OBJECTIVES

The aim of this study was to identify sociodemographic and behavioural factors associated with the prevalence of severe dental fluorosis in moderate- and high-fluoride areas of the Ethiopian Rift Valley.

METHODS

Three hundred and six adolescents (12-15 years) and 233 mothers participated in the study. The children were examined for dental fluorosis according to the Thylstrup-Fejerskov Index (TFI). The children and their mothers were subsequently interviewed. Sixty mothers had more than one participating child. In order to perform a paired parent/child analysis, a total of 73 younger siblings had to be excluded.

RESULTS

Among the remaining 233 children, the prevalence of severe dental fluorosis (TFI >or= 5) was 24.1% and 75.9% in the moderate- and high-fluoride areas, respectively. According to bivariate as well as multivariate analyses, a number of sociodemographic and behavioural factors were related to severe fluorosis. The odds for having severe fluorosis varied according to the fluoride concentration of the drinking water, age, consumption of tea, length of breastfeeding and method of storing water. The adjusted odds ratios ranged from 2.6 to 26.1. Breastfeeding for > 18 months and the use of clay pots for storing drinking water helped protect against severe dental fluorosis. Bivariate analyses indicated that being male and consuming fish might be associated with higher TFI scores.

CONCLUSION

In order to avoid dental fluorosis, low-fluoride drinking water should be provided in the relevant villages. A prolonged period of breastfeeding, the use of clay pots for storing water, and possibly a reduced intake of tea and whole fish in infants might also help to avoid severe fluorosis in children growing up in traditionally fluoride-endemic areas.

Dental fluorosis in primary teeth: a study in rural schoolchildren in Shaanxi Province, China

OBJECTIVE

The aim of this study was to assess the prevalence and severity of fluorosis in the primary dentition of 7-8-year-old Chinese schoolchildren in areas with fluoride concentrations in the drinking water ranging from 0.35 to 7.6 mg L-).

SUBJECTS AND METHODS

Four hundred and seventy-two children from 13 different schools were divided into four groups according to the fluoride concentration of the drinking water: (A) <or=1.0 mg L-1; (B) 1.1-2.0 mg L-1; (C) 2.1-3.8 mg L-1; and (D) 7.6 mg L-1. Clinical examinations were made under field conditions, and dental fluorosis on the buccal surfaces of all teeth was recorded using the Thylstrup-Fejerskov Index (TFI).

RESULTS

The prevalence of dental fluorosis in primary teeth varied from 6.2% to 96.6% according to the fluoride concentration of the drinking water. The differences of median of TFI scores between all groups were statistically significant (P<0.001) except for groups B and C. No statistically significant difference in the severity of dental fluorosis was observed between genders. The second primary molars were most severely affected by dental fluorosis. Disregarding group A, TFI scores between 3 and 4 were most frequently recorded. Dental fluorosis was symmetrically distributed in both jaws.

CONCLUSION

Dental fluorosis is prevalent in the primary teeth of children living in areas supplied with drinking water with fluoride concentrations higher than 1.0 mg L-1. The primary teeth may act as biomarkers of fluoride exposure. The examination of primary teeth may give an early warning of this condition, and thus, provide a basis for intervention to prevent dental fluorosis in the permanent teeth.

Prodromal herpes zoster--a diagnostic challenge in endodontics

This case report highlights the diagnostic challenge that herpes zoster represents if pain develops in the prodromal stage. A 58-year-old male presented with pain in the left maxilla. The symptoms had lasted for 7 months. The first premolar had been extracted soon after the onset, and the second premolar root filled shortly thereafter. Symptoms were experienced as sudden pain attacks lasting for several hours and analgesics gave some pain relief. Clinical examination showed that the second premolar was tender to percussion. No sinus tract or swelling were present. Radiographic examination showed previously root-filled second premolar and first molar teeth, and no evidence of apical pathosis. Due to the uncertainty about the quality of the root filling in the second premolar and incomplete root filling in the first molar, retreatment was started prior to prosthetic treatment in the region. The pain continued and became more intense during the treatment. A diagnosis of herpes zoster was determined, when an acute attack with oedema and vesicles occurred, 2 months after retreatment was started. In the present case, therefore, the primary attack presented itself after months and the herpes zoster diagnosis could not be made until then. points. Key learning points. * A long lasting prodromal stage is an unusual event. * Symptoms combined with inadequate technical standard of root fillings may confuse the diagnostics. * No available data support or suggest the use of antiviral treatment as a diagnostic tool.

Lateral breakdown of nonendodontic origin adjacent to maxillary left incisors

CASE REPORT

A 16-year-old female presented with a labial fistula located between the central and lateral left maxillary incisors. The teeth had normal colour, responded positively to pulp testing, demonstrated negative percussion tests and had no evidence of periodontal pockets. The patient reported no history of trauma, but mentioned that she had received orthodontic treatment. Radiographic examination showed bone loss between these two teeth. Explorative surgery followed by antibiotic treatment was performed, but a fistula reappeared after 22 months. Surgical retreatment combined with antibiotic treatment resulted in gradual healing over a three-year period. No root canal treatment was performed. Aetiological considerations connected to tissue injury and inflammation are discussed. Inflammation induced disturbances in local homeostasis may possibly explain the lateral breakdown of bone. Such areas of reduced resistance may, under unfavourable conditions, be infected by blood-born pathogens. Information about such aberrant cases is important in endodontic decision making.

"Risk periods" associated with the development of dental fluorosis in maxillary permanent central incisors: a meta-analysis

This systematic review of the dental literature (1966-98) concerns risk periods associated with dental fluorosis in the maxillary permanent central incisors. A literature search was organized through the MedLine and the ISI databases. In addition, one unpublished paper (in manuscript) was obtained, as well as one paper published before 1966. However, out of 143 catches, only 10 studies were included in this review. The main reason for exclusions was that the data presented did not meet the criteria given for the present meta-analysis. Among the included papers, 7 pertained to subjects whose exposure to fluoride started at different ages during the enamel formation (Group 1), and 3 were based on subjects who had been exposed from birth and then experienced an abrupt reduction in daily fluoride exposure at different ages during the amelogenesis period (Group 2). The meta-analysis for Group 1 found the odds ratio (OR) for dental fluorosis in children exposed to fluoride early in life (before 2 years of age) to be 7.24 (95% CI; 4.71-11.13) as compared to children exposed later in life (after 2 years of age). The meta-analysis for the studies in Group 2 found the overall OR to be 1.88 (95% CI; 1.35-2.61) for children who had a reduction in fluoride intake after 2 years of age, as compared to individuals who experienced reduction earlier (during the first 2 years). The studies from both groups were pooled and the duration of exposure to fluoride during the first 4 years of life was the independent variable. The meta-analysis now revealed an overall OR of 5.83 (95% CI; 2.83-11.94) for long periods of fluoride exposure (>2 out of the first 4 years) versus shorter periods of exposure (<2 out of the first 4 years of life) during the enamel formation in the maxillary central incisors. Based on the findings of the meta-analysis, no specific period of enamel formation is singled out as being the most critical for the development of dental fluorosis. The duration of fluoride exposure during the amelogenesis, rather than specific risk periods, would seem to explain the development of dental fluorosis in the maxillary permanent central incisor.

Dental fluorosis among persons exposed to high- and low-fluoride drinking water in western Norway

The aim of this project was to study the prevalence and severity of dental fluorosis among persons exposed to moderate- to high- or low-fluoride drinking water in western Norway, and to assess the risk factors involved. Subjects aged 5 to 18 years who had been lifelong consumers of moderate- to high-fluoride groundwater (> or = 0.50 mg F/L) were selected for the study (n = 113). A comparison group (n = 105) was chosen among consumers of low-fluoride surface water (approximately 0.10 mg F/L) in the same district. The Thylstrup-Fejerskov (TF) Index was used to score dental fluorosis. A questionnaire was used to obtain information on fluoride exposure and other relevant factors. Among the consumers of low-fluoride water 14.3% showed dental fluorosis (TF score 1-2) as compared to 78.8% in the group consuming moderate- to high-fluoride water (TF scores 1-7). Premolars were most frequently affected, but severe cases (TF scores 3-7) were equally prevalent in maxillary central incisors and first molars. In logistic regression analysis with TF score 0 or TF score > or = 1 as the dependent variable, only fluoride concentration in the drinking water was associated with a statistically increased risk of dental fluorosis (odds ratio: 18.9; 95% CI: 8.85-40.44). In the study area, which was characterised by multiple fluoride sources, uncontrolled groundwater with moderate to high fluoride content was the most important factor in the development of dental fluorosis. In order to prevent dental fluorosis, groundwater wells should routinely be analysed for fluoride.

Risk periods in the development of dental fluorosis

In order to study the age-related susceptibility to dental fluorosis, 40 children who had been lifelong consumers of moderate- to high-fluoride water (0.55-8.48 mg F/l) were examined, as well as a group of older siblings (n = 40) who were born 6 months to 6 years before the fluoride-containing drinking water was introduced to the household. Background information was obtained through a structured questionnaire. Dental fluorosis was scored according to the TF index. Among the 80 children examined, the permanent incisors were erupted in 66, while 67 had permanent first molars present. As compared to their older siblings, the prevalence of dental fluorosis was significantly higher in the children who had consumed moderate-to high-fluoride water throughout their lives. In a multiple regression analysis, the variable "age when introduced to moderate- to high-fluoride water" came out as the only significant risk factor associated with dental fluorosis. This variable was divided into three categories according to the first exposure to moderate- to high-fluoride drinking water (1) 0-12 months of age, (2) 13-24 months of age and (3) after 24 months of age. Category 3 was used as the reference group. Fluoride exposure starting during the 1st year of life showed the highest odds ratio as compared to exposure only after 2 years of age. The findings indicate that early mineralizing teeth (central incisors and first molars) are highly susceptible to dental fluorosis if exposed to fluoride from the first and--to a lesser extent--also from the 2nd year of life.

[Ground water and health. Reflections based on analysis of water specimens from Hordaland and Vestfold]

Basically, Norway has an ample supply of water. The quality of Norwegian drinking water, however, is threatened, not the least because of pollution of surface water reservoirs. Ground water is better protected against pollution, and sub-surface water sources are being exploited more than before. At present, less than 15% of the Norwegian population uses ground water for household purposes, but the percentage is increasing rapidly Ground water is (normally) clean and has a good taste. A large number of elements can be traced in ground water; some of them in concentrations of significance for human health. The present paper reports elemental analyses of 150 water samples from ground water reservoirs in rock, collected in Vestfold (Eastern Norway) and Hordaland (Western Norway). Sixty-four elements were assessed using modern equipment such as ICP-MS. In most cases the chemical composition of the water was well within the limits set for good quality drinking water. For some of the elements one or more of the results exceeded the "highest acceptable concentrations" as defined by the Norwegian health authorities. This was the case for Al, As, Ba, Ca, Cd, F, Fe, Hg, K, Mg, Mn, Na, P, Pb, Rn and Zn. No drinking water standards have been established for Be, Mo, Th and U, which are of clear significance to the health. More research is needed to assess the relationship between drinking water chemistry and human health. The authors call for a systematic analysis of all Norwegian ground water wells, and emphasise the need for regular quality control, even of small, private water supplies.

Variability in fluoride content of subsurface water reservoirs

Groundwater may contain high concentrations of fluoride. In most countries, however, information on the fluoride content is scarce and anecdotal. The aim of the present study was to make a comprehensive assessment of F- in the groundwater of a representative area of Norway, thereby establishing a more solid basis for appropriate health counseling. Relevant technical information was collected, together with water samples from 1063 underground water sources in 31 municipalities in the county of Hordaland. One thousand and two water samples were analyzed for F- and pH with an F(-)-selective electrode and a pH electrode, respectively. Mean F- was 0.30 mg/l (range, < 0.02-9.48). Fourteen per cent of the wells contained water with F- levels > or = 0.50 mg/l. In three municipalities well water had a mean F- concentration > 0.07 mg/l; in one instance the mean was as high as 1.45 mg/l. In 10 municipalities maximum F- values were > 1.50 mg/l. F- values showed a positive correlation with the pH of the water and the depth of the wells (P < 0.01) and a negative correlation with the age of the well (P < 0.05). The results indicated that low-capacity wells deliver water with a higher F- value than high-capacity wells. This trend, however, was not statistically significant. The results show that high-F groundwater is prevalent and emphasize that information on domestic water supply must be available before supplementary fluoride is prescribed for caries prophylactic purpose.