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Table of Contents   
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 314-318
A survey of attitude and opinions of endodontic residents towards regenerative endodontics


1 Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Jamia Milia Islamia, Faculty of Dentistry, New Delhi, India
3 Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India

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Date of Submission11-Mar-2013
Date of Decision12-May-2013
Date of Acceptance30-May-2013
Date of Web Publication2-Jul-2013
 

   Abstract 

Aim: The objective of this survey was to study the level of awareness, current state of knowledge and opinions towards regenerative endodontic treatments amongst the endodontic residents of India.
Settings and Design: Questionnaire based survey was designed.
Materials and Methods: After approval from the organizing committee of 26 th Federation of Operative Dentistry of India and 19 th Indian Endodontic Society National conference 2011, 200 copies of the questionnaire were circulated amongst the endodontic residents in conservative dentistry and endodontics at various colleges across the country about regenerative endodontic procedures. The survey included profile of the respondents and consisted of 23 questions about their knowledge, attitude and opinions regarding use of these procedures as part of future dental treatment.
Results: The survey showed that half the participants (50.6%) had received continued education in stem cells and/or regenerative dental treatments. The majority of participants were of the opinion (86.6%) that regenerative therapy should be incorporated into dentistry, and most of them (88%) were willing to acquire training in learning this new treatment strategy. The results indicated that half of the participants (52.6%) were already using some type of regenerative therapy in their clinical practice; however, with a majority of these limited to use of membranes, scaffolds or bioactive materials.
Conclusions: These results reflect that endodontic residents are optimistic about the use of regenerative endodontic procedures; however, a need for more research and training was felt.

Keywords: Regenerative endodontics; stem cells; tissue engineering

How to cite this article:
Utneja S, Nawal RR, Ansari MI, Talwar S, Verma M. A survey of attitude and opinions of endodontic residents towards regenerative endodontics. J Conserv Dent 2013;16:314-8

How to cite this URL:
Utneja S, Nawal RR, Ansari MI, Talwar S, Verma M. A survey of attitude and opinions of endodontic residents towards regenerative endodontics. J Conserv Dent [serial online] 2013 [cited 2019 Nov 12];16:314-8. Available from: http://www.jcd.org.in/text.asp?2013/16/4/314/114357

   Introduction Top


Regeneration of dentin-pulp complex is the long-term goal of endodontics and restorative dentistry. Recently, there has been an increasing interest in applying the concept of tissue engineering to endodontics . The creation and delivery of new tissues to replace diseased, missing, or traumatized pulp is referred to as regenerative endodontics. [1] Potential technologies for regenerative endodontics include root canal revascularization, post natal stem cell therapy, pulp implant, scaffold implant, three dimensional cell printing, injectable scaffold and gene therapy. [2] A growing body of evidence is demonstrating the possibility for regeneration of tissues within the pulp space and continued root development in teeth with necrotic pulps and open apexes. Recent case reports from multiple authors support the feasibility of such regenerative endodontic procedures (REP's). [3],[4],[5],[6],[7],[8],[9],[10] The future application of regenerative and tissue-engineering techniques to dentistry holds immense potential for meeting a variety of patient needs. [11]

The next decade of dentistry is speculated to see unparalleled advances in the field of regenerative endodontics. However, there is a need for translation of this novel therapy from labs to the clinics which requires high quality research coupled with collaboration between basic scientists and clinicians. [2] For the same to occur, detailed knowledge of REP's and adequate skills in performing them is of prime importance. Epelman et al. conducted a survey to understand the attitude of the dental practitioners towards this new era of treatment. [12] This study was limited to a small section of endodontists who were members of the college of diplomats of the American Board of Endodontics. More recently another similar survey was carried out amongst the US dentists training in different specialties by Manguno et al.[13] There is a need to survey health-care providers in other geographic locations also, that would help in understanding the global awareness on this topic. No evidence in the scientific literature exists that provides information about the opinions, understanding and attitudes of endodontists in India regarding the delivery of REP's. This survey was thus designed similar to the earlier ones and was carried out on a much larger scale amongst the endodontic residents studying across all institutions in India. These residents are the upcoming generation of endodontists in the nation and form the bulk of potential practitioners and research associates in the next decade. Hence, it is important to understand their opinions, level of awareness and potential acceptance towards this advancement in endodontics. This will also help in ascertaining if more emphasis needs to be given to teaching REP's in the post graduate curriculum and alterations if any are required in the teaching curriculum of the residents pertaining to REP's.

Indian Council of Medical Research has established certain guidelines for stem cell research in which the ethics of using stem cell therapies for dental treatment have not been emphasized. [14] The opinion of the residents might be useful in reframing the guidelines for the safety of regenerative endodontic treatments.


   Materials and Methods Top


After approval from the organizing committee, 200 copies of the questionnaire were circulated at the 26 th Federation of Operative Dentistry of India, and 19 th Indian Endodontic Society National conference 2011 held at New Delhi, amongst the endodontic residents pursuing post-graduation in conservative dentistry and endodontics at various colleges across the country on the issue of REP's. The survey consisted of two parts. The first part contained questions regarding profile of respondents including year of study, age, sex, and demographics. The second part contained 23 questions regarding knowledge and opinions about the use of REP's and their application in a clinical scenario.

The questionnaire data was analyzed by the number of responses as a percentage of the total responses to gain an insight into the majority opinions of the participants as done previously by Epelman et al.[12]


   Results Top


Out of 200 copies of the questionnaire which were circulated 150 completed surveys were received yielding an overall response rate of 75%. Some participants gave more than one reply to each question or did not reply to each question. The questionnaire results are shown in [Table 1].
Table 1: A survey of attitude and opinions of endodontic residents of India towards regenerative endodontics

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Profile of participants

All the participants were in the age group of 25-35 year. (58.6%) of the respondents were females and (41.3%) were males. (41.3%) of students who participated were from South Indian colleges, (24.6%) were from North India, (10%) of participants belonged to colleges from West India and only one respondent was from East Indian college. Remaining (23.3%) participants had not mentioned the location of their post-graduation study. The majority (93.3%) of endodontic residents devoted more than 20 h/week in clinics.

Knowledge, attitude and opinion towards REP's

Half the participants (50.6%) had received continued education in stem cells and/or regenerative dental treatments. The majority of participants were of the opinion (86.6%) that regenerative therapy should be incorporated into dentistry. However, very few of them (14.6%) had used umbilical cord or other types of stem cell banking for themselves or a relative. Most of the respondents (84.6%) believed that stem cell banking would be useful to regenerate dental tissues. More than two third of participants (70.6%) also thought that regenerative stem cell therapies will be used in dentistry within the next decade. More than one third of participants (41.3%) felt that it will be possible to implant new teeth grown in a laboratory in the next 11-20 years. Majority of the participants (88%) were willing to attend training in REP's. Two third of participants (74.6%) thought the greatest obstacle to a patient accepting REP's would be higher cost of treatment, (12%) thought it would be fear of stem cell therapy and the remaining (13.3%) thought it would be due to other reasons. The majority of participants (87.3%) were willing to save teeth and dental tissues for use as part of future REP's. Three fourth of participants (83.3%) thought that REP's could be a more successful treatment than implants, (12.6%) were unsure, and remaining (6%) of the participant didn't consider that REP's could be a better treatment than implant. Majority of participants (83.3%) were of the opinion that REP's should be tested on animals before clinical testing. Most of the participants (85.3%) agreed that the dental professional association should regulate the use of stem cell therapies; only (6.6%) participants didn't want regulation and (8%) were unsure.

Clinical application of REP's

Half of the participants (52.6%) were already using some type of regenerative therapy in their clinical practice, such as membranes, scaffolds or bioactive materials; while the remaining (47.3%) had not used any regenerative therapies during their post graduate training. (46.6%) of participants responded that regenerative treatment would be successful, (45.3%) participants did not know if the outcome of REP's would be successful; few participants (8%) thought it would be unsuccessful. The majority of participants (77.3%) reported that the healing of periapical tissues could be enhanced by REP's. (19.3%) of participants did not know if the healing of periapical tissues could be enhanced by tissue engineering, whereas only five participants (3.3%) thought it would not be enhanced. The participants felt the most valuable application of REP's to be for the pulp tissue revitalization within a root canal (20%). The next would be continued root development in immature teeth as indicated by (9.3%) of participants. 13 (8.6%) agreed that REP's could be used to heal periradicular bone and three (2%) participants thought this kind of treatment could be used to replace avulsed teeth. Majority of participants (60%) however believed that REP's could be applied to all the above mentioned clinical situations. Almost half the participants (48.5%) reported that they come across necrotic immature teeth in 11-25% of their cases. (22%) participants indicated that necrotic immature teeth accounted for less than 10% of cases in their Out-Patient Department (OPD). (20%) responded that 25-50% of their cases involved necrotic immature teeth and 15 of them (10%) reported to have more than 50% of such cases in their OPD. Half of the participants (54%) reported that avulsed or traumatized teeth account for less than 10% of their OPD cases. One third participants (38.6%) reported that periradicular lesion accounted for between 26% and 50% of cases seen in their OPD. (28.6%) participants indicated that even more than 50% of cases in their OPD involved periradicular lesions; (22.6%) indicated such cases to be between 11% and 25%, while remaining 10% reported that occurrence of such cases to be less than 10%. More than half of the participants (54%) consider the application of calcium hydroxide followed by mineral trioxide aggregate (MTA) apical plug and backfilling with obturation material to be the optimum treatment for necrotic immature teeth. Only one eighth participants agreed that application of triple antibiotic paste and pulp regeneration would be the optimum treatment for necrotic immature teeth. Majority of participants (76.6%) were willing to collect dental tissue for stem cell bank. Most of the participants (50.6%) believe that the cost of REP's should be more than current treatment. The majority of participants (53.3%) would recommend stem cell treatment and REP's to their patients if it was the most effective treatment option.


   Discussion Top


The discovery of stem cells in the pulp of permanent and deciduous teeth raised the intriguing possibility of using dental pulp stem cells for tissue engineering. [15] Recent advances in the identification and characterization of dental stem cells, and in dental tissue-engineering strategies, suggest that within the next decade, bioengineering approaches may successfully be used to regenerate dental tissues and whole teeth. [11] In order for this approach to reach clinical relevance in human, adequate interest and knowledge backed by research amongst the service providers is the prime requisite. This survey was hence conducted to collect data about the level of awareness, knowledge and present clinical status about stem cell therapies and REP's amongst the endodontic residents of our country. The survey yielded a very enthusiastic response from the residents, wherein nine out of ten felt that regenerative therapy should be incorporated into dentistry. More than two third of participants were optimistic about its use in dentistry in the next decade, and nearly one third felt this new approach would be successful to the level of possibility of implanting laboratory grown teeth. This positive response could be due to the recent surge in public discussions on this topic through various forums including an increase in tissue engineering articles published in scientific journals, talks based on stem cell therapies and news dominating dental and medical tribunals. [16],[17]

Most residents were willing to save teeth and dental tissues through REP's and preferred it over implants as a treatment option, However, almost all felt a need to attend training in REP's, reflecting an underlying lack of knowledge. According to the majority of respondents another prerequisite to carry out REP's would be proper ethical regulation by the respective professional associations. Epelman et al. in their study also stressed on the importance of such regulations to come in place. [12] For REP's to become the mainstay of treatment modalities a strong research backing is warranted; wherein most respondents felt that these should be tested on animals before clinical application. In spite of enthusiasm and willing attitude, only one fifth respondents had used stem cell banking for themselves or relatives. In fact, they felt that the biggest deterrent for patients to accept this treatment modality would be the fear of stem cells, followed by the high cost. In their opinions, REP's should be priced such that it is equally affordable to patients as other standard procedures.

In clinical practices, almost half of the residents were doing some type of REP's, with a majority of these limited to use of membranes, scaffolds or bioactive materials. Most of the residents were aware of other REP procedures but were unsure about its results. Half of them were of the opinion that REP's could be used in various applications like healing of periradicular bone, continued root development in immature teeth, pulp tissue revitalization within a root canal and tooth re-implantation. However, only one eighth respondents have found regenerative techniques valuable in treating necrotic immature teeth which constituted 20% of patients reporting to them. More than half of the participants still consider the application of calcium hydroxide followed by MTA apical plug and backfilling with obturation material to be the optimum treatment for necrotic immature teeth. This gives an insight to the fact that the residents are not trained in performing advanced regenerative endodontic techniques. There is a need for continuing education and training programs related to all treatments that accomplish pulp-dentin regeneration from the simplest blood clot revascularization method to the most complex treatment, which involves creating tissue-engineered dental pulp constructs in the laboratory and implanting them into cleaned and shaped root canals.

Safeguards have to be in place to protect research participants receiving stem cell transplants, and patients at large from receiving unproven stem cell therapies. In India, Indian Council of Medical Research has taken an initiative to lay down the guidelines pertaining to stem cell research which were revised in March 2012. [14] These apply to all stakeholders' viz. individual researchers, organizations, sponsors, oversight committees and others, associated with research on human stem cells and for their derivatives, both basic and clinical. However, there is a need for the creation of more expansive guidelines covering all REP's in addition to these guidelines to protect patients and health care providers.


   Conclusion Top


The survey participants expressed general optimism and at the same time showed a consensus on the need for research and training towards REP's. An impending need was felt amongst the residents for ethical regulation of REP's and guidelines for protecting patients by local governing bodies. More survey research like this should be conducted amongst health-care providers in other geographic locations that would help in understanding the global awareness on this topic. This data along with further research would help in standardizing REP's worldwide.


   Acknowledgment Top


We would like to sincerely thank Dr. Sanjay Miglani, Organising Secretary of the Federation of Operative Dentistry of India/Indian Endodontic Society conference, New Delhi for giving his guidance and support.

 
   References Top

1.Saber SE. Tissue engineering in endodontics. J Oral Sci 2009;51:495-507.  Back to cited text no. 1
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2.Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: A review of current status and a call for action. J Endod 2007;33:377-90.  Back to cited text no. 2
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3.Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185-7.  Back to cited text no. 3
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4.Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200.  Back to cited text no. 4
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5.Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: A paradigm shift. J Endod 2006;32:1205-13.  Back to cited text no. 5
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6.Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29:47-50.  Back to cited text no. 6
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7.Jung IY, Lee SJ, Hargreaves KM. Biologically based treatment of immature permanent teeth with pulpal necrosis: A case series. J Endod 2008;34:876-87.  Back to cited text no. 7
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8.Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF. Pulp revascularization of immature teeth with apical periodontitis: A clinical study. J Endod 2009;35:745-9.  Back to cited text no. 8
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9.Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: A case series. J Endod 2010;36:536-41.  Back to cited text no. 9
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10.Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using platelet-rich plasma: A case report. J Endod 2011;37:265-8.  Back to cited text no. 10
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11.Duailibi SE, Duailibi MT, Vacanti JP, Yelick PC. Prospects for tooth regeneration. Periodontol 2000 2006;41:177-87.  Back to cited text no. 11
    
12.Epelman I, Murray PE, Garcia-Godoy F, Kuttler S, Namerow KN. A practitioner survey of opinions toward regenerative endodontics. J Endod 2009;35:1204-10.  Back to cited text no. 12
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13.Manguno C, Murray PE, Howard C, Madras J, Mangan S, Namerow KN. A survey of dental residents' expectations for regenerative endodontics. J Endod 2012;38:137-43.  Back to cited text no. 13
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14.Ganguly NK. Guidelines for stem cell research and therapy. Department of biotechnology and Indian council of medical research. New Delhi: Royal Offset Printers; 2012.  Back to cited text no. 14
    
15.Cordeiro MM, Dong Z, Kaneko T, Zhang Z, Miyazawa M, Shi S, et al. Dental pulp tissue engineering with stem cells from exfoliated deciduous teeth. J Endod 2008;34:962-9.  Back to cited text no. 15
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16.Nakashima M, Akamine A. The application of tissue engineering to regeneration of pulp and dentin in endodontics. J Endod 2005;31:711-8.  Back to cited text no. 16
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Correspondence Address:
Ruchika Roongta Nawal
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, MAMC Complex, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0707.114357

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