Journal of Investigative and Clinical Dentistry (2015), 0, 1–9

ORIGINAL ARTICLE Endodontics

Perceptions of single-visit and multiple-visit endodontic treatment: a survey of endodontic specialists and general dentists in Hong Kong Amy Wai-Yee Wong, Shinan Zhang, Cheng-Fei Zhang & Chun-Hung Chu Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

Keywords endodontic, endodontist, general dentists, single-visit, survey. Correspondence Dr Cheng-Fei Zhang, Faculty of Dentistry, The University of Hong Kong, 3A15, Prince Philip Dental Hospital, 34 Hospital Road, Hong Kong SAR, China. Tel: +852-2859-0371 Fax: +852-2559-9013 Email: [email protected] Received 8 December 2014; accepted 5 February 2015. doi: 10.1111/jicd.12154

Abstract Aim: To study the preference of practice for single- and multiple-visit endodontic treatment by Hong Kong endodontists and general dental practitioners (GDPs), and to investigate their reasons for choosing single- or multiple-visit treatment in their practice. Method: An anonymous questionnaire was mailed to all 16 registered endodontists and 800 randomly selected GDPs in Hong Kong to explore their preference and reasons for selecting single- or multiple-visit endodontic treatment for their patients. Information on the use of magnifying loupes, microscopes and the number of years they have been in dental practice was also collected. Results: Eight endodontists and 429 GDPs returned their questionnaires and the response rate was 50% and 53.6% respectively. Among the GDPs, 404 (94.2%) undertook endodontic treatment in their practices. For those performing endodontic treatment, the mean number of years of practice was 23.6  4.8 for endodontists and 15.3  9.1 for GDPs. Seven endodontists (87.5%) used a surgical microscope. For GDPs, only 25 (6.2%) used a surgical microscope and 123 (30.4%) used magnifying loupes during endodontic treatment. Seven endodontists (87.5%) and 375 GDPs (92.8%) predominantly performed multiple-visit treatment. The commonest reasons for choosing multiple-visit treatment for both endodontists and GDPs were the positive effects of interappointment medications (n = 3, 37.5%) and that the tooth to be treated had doubtful prognosis (n = 103, 25.5%). The commonest reason for choosing single-visit treatment for both endodontists and general dentists was that treatment could be completed in one visit (n = 4, 50%) and (n = 127, 31.4%). Conclusion: Most Hong Kong endodontists and GDPs preferred offering multiple-visit endodontic treatment.

Introduction Traditional endodontic (root canal) treatment used to take multiple visits to complete, with one of the main reasons for this being the length of time required to complete the treatment. However, the use of contemporary endodontic techniques and equipment such as magnifying ª 2015 Wiley Publishing Asia Pty Ltd

devices, electronic apex locators, engine-driven rotary nickel titanium files, and so forth, has not only increased the success rate of endodontic treatment but also shortened the time needed for the treatment. Endodontic treatment may therefore be completed in a single visit. In fact, the concept of single-visit endodontic treatment is not new; the single- versus multiple-visit endodontic treatment has 1

Single- versus multiple-visit treatment

been the subject of discussion among dental professionals for many years, with as yet no definitive conclusion to the debate.1 Some of the unresolved issues include possible differences in the anticipated success rate, clinical outcomes, microbiological concerns, pain, and other posttreatment complications. This controversy can be investigated and a recent systematic review of the literature did not reveal a significant difference in treatment outcome.2 With respect to the decision to choose a single- or multiple-visit endodontic treatment, clinicians may be influenced not only by effectiveness, complications, and cost but also by factors such as patient and/or operator comfort, preference, and satisfaction.3 Some clinicians’ choice may have been affected by what they were taught when they were dental students, and their training would have varied between dental schools. Sathorn et al.1 pointed out that an important consideration in treatment decision-making was the human factor. The treatment decision-making is highly dependent on the dentists, and they in general are more influential than any other party in the treatment decision. In many cases they are not likely to offer patients a choice between single- and multiple-visit treatments because their clinical perceptions including treatment philosophy, rationale, and preference for the different treatment options are unavailable to the patients.1 This lack of offered options in particular pertains to endodontic treatment, which is a skill-demanding procedure. The choice of treatment primarily depends on the dentist’s skill and professional knowledge, experience and preference, comfort, habit, and convenience. The implementation of new concepts, treatments, or techniques may depend not just on their biological rationale or effectiveness. Some clinical procedures are not widely implemented for the simple reason that they are too difficult or too inconvenient to perform, even though they have a strong functional rationale. Infrequent use of magnifying loupes and the application of a rubber dam are two common examples in dental practice. Messer4 concluded that the clinical judgment for general dental practitioners (GDPs) on endodontic treatment was complicated and did not rely simply on the practical clinical aspects. The preferred method of endodontic treatment may not vary across cultures. A recent study in Brazil reported that Florianopolis (Brazil) endodontists preferred multiple- over single-visit endodontic treatment when the tooth had pulp necrosis.5 Another study reported that Australian endodontists strongly preferred multiple- over single-visit root canal treatment, even in cases where biological concerns were not an issue and that operator preference appeared to be the primary determinant of treatment choice.1 Inamoto et al.6 suggested that single-visit endodontic treatment was not 2

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popular in Japan, and in the United States only approximately one-third of the dentists would perform rootcanal obturation at the first visit in infected root-canal cases. One survey also reported that most Flemish GDPs completed the endodontic treatment over two visits.7 However, patients’ expectations can differ sharply from dentists’ preference. A study using a self-administered questionnaire in the United States found most patients preferred single-visit endodontic treatment regardless of success rates.8 Simons and Williams9 presented a complete endodontic audit and discussed improvement of patient care and treatment outcomes in endodontics. It is possible that insurance payment systems may influence the choice of treatment. A dentists’ choice of treatment could be altered if item-of-service payment is remunerated according to single- and multi-rooted teeth with no fee difference for the number of visits. A literature search found that no study had been conducted to investigate dentists’ preference for choosing single- or multiple-visit treatment in Hong Kong. The objectives of this study were therefore to study the preference for single- and multiple-visit endodontic treatment by endodontic specialists and general dentists in Hong Kong, and to investigate their reasons for choosing single- or multiple-visit treatment in their practices.

Method Recruitment of participating dentists This study was conducted in February to June 2014 with ethics approval from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB UW No. 14131). The target sample consisted of two groups: endodontists and GDPs. There are 2087 GDPs on the general register and 16 endodontists on the specialist register of the Hong Kong Dental Council. We invited all 16 registered endodontists and we randomly selected 800 GDPs to participate in our questionnaire survey. An invitation letter was first sent in February 2014 with an anonymous self-administered questionnaire attached (Figure 1). The recipients were asked to complete and return the questionnaire with the self-addressed stamped envelope or by facsimile. A reminder mail was then sent to all invited clinicians 4 weeks later to increase the return rate of the questionnaire. Questionnaire design In order to design the questionnaire, a systematic literature search was performed.2 Two hundred papers in the English language were screened and 39 clinical trials were ª 2015 Wiley Publishing Asia Pty Ltd

A.W.-Y. Wong et al.

Single- versus multiple-visit treatment

Endodontist’s Perception of Single-visit and Multiple-visit Root Canal Treatment This survey aims to investigate the current practice of root canal treatment (RCT). There is no right or wrong answer to the questions below so please choose the answer that represents your opinion. Q1. Are you currently practicing RCT?

ˎ Yes

ˎ No (End of survey. Thank you.)

Q2. How are you currently practicing RCT?

ˎ Only single-visit ˎġġġOnly multiple-visit ˎ Predominantly single-visit ˎ Predominantly multiple-visit ˎġġġBoth single-visit and multiple-visit equally

Q3. What factors would you consider for multiple-visit RCT? A. Lengthy treatments can be shortened into several appointments (e.g. curved canal, multiple canals) B. Tooth with doubtful prognosis can be assessed during the treatment process C. Positive effects of inter-appointment medications dressed in root canal(s) D. Allow time for lessening of symptoms before obturation (e.g. pain, abscess) E. Reduction of post-operative pain F. High success rate G. Easy collection of treatment fees for multiple visits H. Dentists’ preference/favourable previous experience I. Patients’ preference/favourable previous experience J. Patient time constraint K. Dentist time constraint L. Others (please specify): _________________________ Q4. Which factor above in Q3 would you consider the most important for you to do multiple-visit RCT? Q5. A. B. C. D. E. F. G. H. I. J. K.

Agree

Neutral

Disagree

ˎ

ˎ

ˎ

ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

________________________ (Put a letter from A to L).

Which factors would you consider for single-visit RCT? Better recall of root canal morphology within same visit Lower risks and complications of local anesthetics Decreased instrumentation procedural errors Decreased material wastage Treatment can be completed in one visit High success rate Dentists’ preference/favourable previous experience Patients’ preference/favourable previous experience Patient time constraint Dentist time constraint Others (please specify): _________________________

Agree ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

Q6. Which factor above in Q5 would you consider the most important for you to do single-visit RCT?

Neutral ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

Disagree ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ ˎ

________________________ (Put a letter from A to K).

Q7. Do you perform RCT using a magnifying loupe?

ˎ Yes

ˎ No

Q8. Do you perform RCT using a microscope?

ˎġ Yes

ˎġġNo

Q9. In general, would you prefer multiple-visit or single-visit RCT?

ˎ Multiple-visit

ˎ Single-visit

Q10. How many years have you been practicing dentistry?

____________ years

The End. Thank you. Figure 1. Anonymous self-administered questionnaire.

ª 2015 Wiley Publishing Asia Pty Ltd

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included in the review. The common factors influencing the choice of using single- and multiple-visit endodontic treatment were identified. In the questionnaire, we sought information on clinicians’ perception of single- and multiple-visit endodontic treatment via a total of 10 closed questions fitted on one page. The questionnaire was piloted on 10 private general dental practitioners and a professor specializing in endodontics; feedback was collected and amendments made accordingly before the main study. The final questionnaire contained a list of identified common factors that might influence the decision for choosing a single- or multiple-visit endodontic treatment, such as patient preference and high success rate. The participants were asked to indicate their degree of agreement with the statements on a three-point Likert scale (agree; neutral; disagree). Other questions, such as number of years of clinical dental practice, usage of magnification devices (magnifying loupes and microscope), and preference for, and frequency of, single-visit and multiple-visit endodontic treatment, were also asked. It generally should have taken

Perceptions of single-visit and multiple-visit endodontic treatment: a survey of endodontic specialists and general dentists in Hong Kong.

To study the preference of practice for single- and multiple-visit endodontic treatment by Hong Kong endodontists and general dental practitioners (GD...
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