Undergraduate Endodontic Training and Its Relation to Contemporary Practice: Multicenter Cross-Sectional Study in Saudi Arabia

Materials and Methods An online questionnaire was developed and emailed to all dental schools in Saudi Arabia. This questionnaire was answered by the endodontic undergraduate program director. The data collected were analysed using descriptive statistics. Results The response rate was 96.15%, which means twenty-five out of twenty-six dental schools participated in the study. The majority of the academic supervisors was endodontists (92%). The use of magnification and ultrasonic tips was not required by 84% and 76% of the dental schools, respectively. The main endodontic treatment techniques were the step-back technique and gates glidden for cleaning and shaping (76%) and cold lateral compaction for obturation (92%). Conclusions The dental students were supervised by endodontic specialists and trained to use traditional endodontic methods. Encouraging dental educators to train students to use modern technology and equipment would probably improve their graduate clinical skills and performance.


Introduction
General dentists are usually the frst to encounter patients in dental pain and provide emergency or complete endodontic care [1,2]. Root canal treatment (RCT) is a meticulous dental procedure that involves the use of multiple instruments, materials, devices, and radiographs. Terefore, the quality of RCT in dental radiographs is often described as inadequate or substandard [2][3][4][5]. Te quality of the RCT is one of the main predictors of postoperative peri-radicular healing [6,7]. Undergraduate students usually feel incompetent in performing one or several steps of RCT [8][9][10][11].
Te perception of lack of confdence does not necessarily refect the competence of dental students [12]. However, it may emphasize the complexity of the procedure or the need to increase the extent of undergraduate clinical training. Unfortunately, increasing the time of undergraduate endodontic training may not be permissible since there is a need to achieve competency in several other dental specialties. Te European Society of Endodontology emphasized quality over quantity in clinical training. Te society also preferred that students be supervised by endodontic specialists. Te assumption is that endodontic specialists will improve the standard of supervision in undergraduate training [13]. A lower student-faculty ratio also allows for an individualized learning experience and time for refection on clinical practice and feedback [14].
Modern endodontic techniques have been developed to overcome the difculty of RCT [15][16][17]. Modern endodontics incorporates advanced equipment and materials such as nickel-titanium NiTi fles, microscope, and mineral trioxide aggregate (MTA). Te introduction of rotary fles has improved the operator's efciency in shaping the root canals. Moreover, it improved the quality of the RCT [15][16][17]. Furthermore, heat treatment of NiTi fles and the use of reciprocation movement have reduced the number of fles needed to complete the procedure and improved the shaping quality of RCT [18]. Finally, thermal technology and reciprocating motion signifcantly increased the cyclic fatigue resistance of rotary fles [18][19][20][21]. Terefore, the use of heat-treated rotary fles and the incorporation of reciprocation motion will increase RCT efciency, safety, and quality [18][19][20]22].
Magnifcation was also introduced to the feld of dentistry to improve clinical precision and posture [23][24][25]. It becomes necessary in the feld of endodontics to improve the predictability and accuracy of the clinical procedure [26][27][28]. Because it will help the clinician fnd canals and cracks that are not visible to the naked eye. Te dental students found that magnifcation improved their efciency and the quality of their performance [29,30].
Ideally, students need to practice RCT using modern technology and resources that will improve their clinical performance. Although the clinical outcome of the RCT was the same using traditional techniques [31], modern technology allowed for signifcantly fewer appointment visits, posttreatment interventions, and mishaps [31,32]. Terefore, progressive advancement elevates the clinical experience for the practitioner and the patient. Since dental patients are usually interested in painless treatment and short dental visits, the American Association of Endodontists has incorporated modern equipment and techniques into the standard of practice for contemporary endodontics [33]. However, international guidelines in endodontic education do not outline materials or equipment that will be needed by dental students [34,35]. Terefore, the objectives of this study were to explore the current state of endodontic practical training in Saudi dental schools and its relevance to contemporary endodontic practice.

Materials and Methods
Te study was registered, and ethical approval was obtained from the institutional review board of the Princess Nourah Bint Abdulrahman University (IRB: 20-0165).
Te questionnaire was developed from a study that was conducted in the United Kingdom about undergraduate endodontic education [36], and it was modifed to meet the study objectives. It included ten questions that covered the practical aspect of endodontic practical training, along with three questions about resources available for dental students (Table 1). SurveyMonkey (Momentive Inc., CA, USA) was used to create the online format of the questionnaire.
Te names and numbers of all public and private dental schools in Saudi Arabia were obtained from the Ministry of Education website. Further details about dean names and contact information were obtained from the Saudi Dental Education Society. Te deans were then contacted to permit study conduction in their institutions and forward the online questionnaire to the undergraduate endodontic program. Te data was collected in Excel sheets, and descriptive statistics were used to analyze it.
Endodontic undergraduate training usually commences with preclinical instruction in the third academic year, followed by clinical training in the fourth and fnal years. Tere are no national guidelines for undergraduate endodontic education defning a minimum number of required preclinical and clinical training hours [37].

Results
Twenty-fve out of twenty-six dental schools participated in the study, indicating a response rate of 96.15%. Te answers to the survey questions are presented in Table 2. In almost all of these schools (92%), the majority of instructors supervising undergraduate students during their endodontic training were endodontists. Te supervisor-student ratio was 1 : 8 or less in preclinical and clinical training. Te use of magnifcation was not applied by 84% of the dental schools ( Figure 1). Te ultrasonic tips were not used by most schools (76%). Only a few schools use them for removing posts and broken instruments (12%). Tey are rarely used for access refnement (5%). All dental schools train students to use manual fles for RCT (100%), while some dental schools also train students to use rotary fles (52%). Students are unlikely to use reciprocation fles in their undergraduate training (8%).
Te main method of root canal preparation was the stepback technique using K fles and gates glidden (76%). Alternatively, students were trained to use the crown-down technique with K fles and gates glidden (16%). One school trained the students to use the hybrid technique, using K fles and orifce openers as the main shaping techniques. Te main irrigants were sodium hypochlorite alone (36%), or sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA) as a fnal wash (36%). Four dental schools mentioned the use of saline as a fnal wash after sodium hypochlorite (16%). Te main irrigation techniques were passive needle irrigation (68%), and manual agitation (32%).
Te main technique of obturation was cold lateral condensation (92%). One dental school trained students to use warm vertical compaction only in preclinical courses, and another school allowed the students to obturate using a single cone technique in addition to the cold lateral condensation technique. Most students were not trained to interpret the CBCT scans (60%). Moreover, 60% of dental schools instruct their students to use calcium hydroxide Ca(OH) 2 selectively based on the case. Te temporization protocol in around half of the dental schools was a spacer and cavit (56%). Te alternative protocol is cavit, covered by glass ionomer cement (GIC) or intermediate restorative material (IRM). International Journal of Clinical Practice 3 Mineral trioxide aggregate (MTA) is available for dental students' use in the majority of dental schools (92%). Some schools provide heat-treated fles (36%), retreatment fles (40%), microscopes (32%), CBCT (44%), and C + K fles (36%), respectively, for dental students. Other advanced equipment and materials, such as reciprocating fles, are infrequently made available to undergraduate dental students. Finally, two dental schools mentioned traditional NiTi rotary fles as an advanced instrument.

Discussion
Te majority of dental students in the surveyed dental schools are trained by endodontic specialists. Te supervision ratio does not exceed one instructor per eight students. Practical training mainly involved traditional techniques in shaping, irrigation, and obturation. Te students are not required to use magnifcation and are taught to use Ca(OH) 2 selectively, as well as to temporize with a spacer and temporary restoration.
Te European Society of Endodontology recommended that dental students' training be ideally supervised by a specialist in endodontics [13]. Te present study showed that 92% of dental schools in Saudi Arabia assigned endodontic specialists to supervise their undergraduate dental students. While around 60% to 65% of the United Kingdom and Spain's dental schools provide dental supervisors who are specialists, the supervisor-to-student ratio in Saudi dental schools was approximately similar to the ratio reported in Spain and the United Kingdom [36,38].
A learning curve is required when adopting rotary NiTi fles in root canal instrumentation, since experienced clinicians have fewer endodontic mishaps [39][40][41]. However, dental clinicians who were trained to use rotary fles needed a shorter time to complete the procedure and experienced fewer iatrogenic errors [39][40][41]. Moreover, manual stainless steel fles are less fexible in comparison to NiTi fles [42]. Rotary NiTi fles conserve the root canal structure and cause less transportation [32]. Terefore, NiTi rotary or reciprocating fles can be considered an essential instrument for modern standards of care. Te standard of practice for contemporary endodontics in the American Association of Endodontics standard incorporated the use of NiTi fles in addition to CBCT, magnifcation, and endodontic microinstruments [33].
MTA was available for dental students, which is the ideal material for vital pulp therapy and perforation repair [43,44]. Training students on using the MTA properly will improve treatment outcomes in these situations [43,44]. Unfortunately, MTA is known to cause discoloration and is associated with handling difculties [44]. Alternatively, bioceramic materials have been proposed to improve the shortcomings of MTA [45].
In accordance with the present fndings, a previous study on dental schools in Spain found that students rarely use magnifcation and are rarely trained to use ultrasonic tips [38]. Most dental schools in the United Kingdom, on the other hand, teach their students how to use ultrasonic tips [36]. Ultrasonic tips are microinstruments that are frequently used in conjunction with magnifcation to refne the access, remove the dental blockage, and fnd the root canals [46]. When endodontists used magnifcation, the chances of detecting canals such as the second mesiobuccal canal (MB2) in frst maxillary molars increased threefold [47,48]. Terefore, the magnifcation allowed clinicians to complete the endodontic treatment in a shorter period of time [48]. Tat said, only 33% of the dental schools in the United Kingdom train students to use loupes and microscopes, and 27% of dental schools train students to use dental loupes only [36]. Tis is similar to the results found in the present study, where 32% of Saudi dental schools train their students on the use of microscopes. Micro-CT analysis of maxillary molars for the Saudi population revealed that MB2 was detected in 97% of maxillary frst molars, and in 70% of these cases, the MB2 canals were not easily located on the pulp foor [49]. Nonetheless, the adoption of magnifcation loupes in dental training led to better posture, precision, and efciency for students [29,30,50].
Students were mainly encouraged to use Ca(OH) 2 selectively based on the case and temporize with spacer and cavit. Despite the fact that calcium hydroxide is well known for its antibacterial properties [51][52][53], the clinical usefulness of this medicament for endodontic procedures is controversial [51][52][53]. However, no adverse efects were reported when Ca(OH) 2 was used between dental appointments for a shorter period of time [51][52][53]. Students should be encouraged to complete the treatment in a single visit since a single-visit endodontic procedure reduces postoperative complications and improves patient compliance [54,55]. Te use of spacer for temporization is also controversial since it may jeopardize the sealing of the root canal system [56,57]. A recent survey found that the majority of dentists in Saudi Arabia use the same temporization techniques taught in dental schools [58]. Tefon spacers were found to be a better alternative to cotton pellets [59,60]. However, cavit restoration is only used for less than two weeks and deteriorates easily under masticatory forces [56,57,61]. Te use of alternative temporization techniques such as cavit covered by glass ionomer can be thoughtfully considered, especially after obturation and for a longer period of temporization [61].
Te outcome of RCT in conventional endodontic practice was similar to that in contemporary practice since the objectives of the treatment were the same [31]. Nevertheless, conventional modalities were found to increase treatment time and postoperative interventions [31,32]. Since evidence suggests that modern technologies and techniques facilitate the efciency and predictability of RCT, these technologies and techniques will make it easier for graduate dentists to achieve RCT objectives, especially since the quality of root canal treatment has been criticized internationally and nationally [2-5, 31, 32].
Currently, there are no national guidelines for undergraduate endodontic education determining the necessary material and equipment that students should be competent to use; in contrast, the American Association of Endodontists adopted modern techniques and technologies as a standard of practice [33]. Outlining the equipment and Table  2: Te qualifcation and ratio of dental supervisors in addition to procedural training in Saudi dental schools.
Te topic   International Journal of Clinical Practice materials that have to be available for students will be essential for standard practical training. Te development of a national or international framework for undergraduate endodontic education can guide educators in fnding consensus that allows them to adopt best practices in education and endodontics [37].

Conclusions
Dental students were supervised by endodontists, with one endodontic supervisor monitoring up to eight dental students. However, undergraduate dental students were mainly trained to use conventional modalities of treatment. Te incorporation of advanced techniques and instruments in endodontic training was recommended.

Data Availability
Te datasets generated and/or analysed during the current study are available as a supplementary fle.

Ethical Approval
Te study was registered, and ethical approval was obtained from the institutional review board of the Princess Nourah Bint Abdulrahman University (IRB: 20-0165).

Consent
Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest
Te authors declare that they have no conficts of interest.