Endodontic Infection Control in General Dentistry : Barriers, Facilitators, and Clinical Practice

Apical periodontitis is a very common condition. Epidemiological research suggests that nearly 50% of the global adult population may have had at least one affected tooth and that approximately 40% of root-filled teeth may be associated with apical periodontitis. Since apical periodontitis is caused by microorganisms in the root canal system, every measure taken to reduce the microbial burden during treatment is of importance. The high prevalence of apical periodontitis associated with root-filled teeth suggests that dentists in general may have problems eliminating microorganisms in the root canals and avoiding contamination of the root canals when performing endodontic treatments.  Most non-surgical endodontic treatments are performed by general dentists. It can be assumed that improvement of endodontic infection control in general dentistry could have a positive impact on the overall outcome of endodontic treatments. The aim of this project was to render a better understanding of endodontic infection control in general dentistry.  Study I and II consisted of a two-folded cross-sectional questionnaire regarding general dentists’ endodontic infection control measures, sources of knowledge, and self-assessed skills. Study III and V consisted of two cross-sectional mixed methods surveys regarding dental health care workers’ experiences during the COVID-19 pandemic, and perceived barriers and facilitators to hand hygiene adherence. Study IV was a prospective observational study which evaluated endodontic operative field asepsis by assessing general dentists’ ability to reduce the contamination to a non-cultivable level. The vast majority reported using a dental dam and most disinfected the endodontic operative field. However, one in 10 did not use hand disinfectant at all during endodontic treatments. More than half of the respondents did not know, or did not believe, that the initial diagnosis affected the outcome of their endodontic treatments, indicating an underestimation of microbiological factors’ impact on treatment outcome. The majority graded their endodontic treatment outcome and their infection control adherence as good, though several admitted not fully adhering to the infection control guidelines. The clinical study found relatively high levels of contamination on the operative field in general dentistry, which indicates poor aseptic control. Knowledge, education, and a supportive work environment were perceived as facilitators to infection control. Recurring themes regarding barriers were a lack of training and performance feedback, conflicting messages and conflicting demands, and lack of resources (mainly time). Several respondents reported situations where they had felt pressured to make compromises with their infection control measures.  Most based their endodontic management of patients on what they had been taught during their undergraduate training. A third of the general dentists had not attended any continuing endodontic education.  The results from the included studies show that although dental professionals may have the intention to adhere to infection control guidelines, they are influenced by various other factors, which may result in nonadherence. There are also indications that the awareness of the risks of contamination occurring during treatment, and the subsequent negative impact contamination may have on treatment outcome, may be lacking. Although both dentists and other dental health care workers graded their knowledge and performance of, for example hand hygiene, as good, several other responses indicated their estimations may be misestimations.  Further research into what affects endodontic infection control performance is needed, particularly regarding hand hygiene. Additional attention must be paid to the settings in which general dentists operate, as the ability to choose different measures may be limited by environmental and organizational factors. The future challenge is to raise awareness in general dentistry about the microbiological aspects of endodontic treatments and the critical importance of infection control. It would be of value to add more observational data to compare views with what is performed in clinical practice

Endodontic infection control routines among general dental practitioners in Sweden and Norway : a questionnaire survey.

Objective: The purpose of this study was to investigate endodontic infection prevention and control routines among general dental practitioners in Sweden and Norway. Materials and methods: A questionnaire were sent by email to 1384 general dental practitioners employed in Sweden and Norway. The participants were asked questions concerning different aspects of infection prevention and control during endodontic treatment; use of rubber dam, sealing of rubber dam, antibacterial solutions, and use of hand disinfectant and gloves. Results: The response rate was 61,4 % (n 819). 96,9 % reported routinely using rubber dam during endodontic treatment. 88,3% reported always, or sometimes, sealing the area between rubber dam and tooth. Most disinfected the endodontic operative field, but the antibacterial solutions used varied. 11,9 % did not use gloves at all during treatment, and 10,5 % did not use hand disinfectant during treatment. Conclusions: Most of the general dental practitioners took measures to establish and maintain aseptics during endodontic treatment, which infers an awareness of the importance of endodontic infection prevention and control. But the results were self-reported and there may be a gap between claimed and actual behavior. Further studies using observation methodologies are needed to assess how infection control routines are performed in everyday clinical practice

Det endodontiska arbetsfältet : aseptik och antiseptik i den kliniska vardagen

Inom tandvården sker behandlingar i en miljö som är mycket rik på mikroorganismer och med risk för smittspridning. För att minska denna risk behöver vi aktivt verka för att reducera smittkällor och bryta transportvägarna för mikroorganismer. Att arbeta aseptiskt och därmed «bevara det rena rent» är en grundläggande princip vid endodonti. Ett aseptiskt arbetsfält skapas med hjälp av kofferdam och antiseptika, och detta aseptiska arbetsfält måste upprätthållas under hela behandlingen. 90 % av svenska och 30 % av de danska tandläkarna använder kofferdam regelbundet. Trots införandet av flera nya tekniker för både instrumentering och rotfyllning under senare år ses inte någon minskad mängd apikal parodontit i befolkningen. Det är troligt att andra faktorer, som till exempel det aseptiska och antiseptiska tillvägagångssättet, kan spela en större roll för utfallet av den endodontiska behandlingen än vad som tidigare antagits.In dentistry the treatments take place in an environment that is very rich in microorganisms, and there is a risk of transmission of infection. In order to reduce that risk, we need to actively work to minimize the sources if infection, and break the routes of transmission. Working aseptically and thus reducing the probability of contamination, is a fundamental principle. An aseptic operative field is created by the use of a rubber dam and antiseptics, and these aseptic conditions must be maintained during the whole procedure. 90% of Swedish and 30% of Danish dentists use rubber dam regularly. Though several new techniques for both instrumentation and obturation have been introduced in recent years, no reduction of the prevalence of apical periodontitis can be seen. Other factors, such as the aseptic and antiseptic approach probably plays a more important role in the outcome of the endodontic treatment than previously assumed

Swedish dental health care workers' sense of safety and satisfaction with the information they received during the COVID-19 pandemic

OBJECTIVE: The aim was to explore what affected dental health care workers' sense of safety while working during the COVID-19 pandemic and examine their satisfaction with the information they received on COVID-19 and pandemic protocols. MATERIAL AND METHOD: An invitation to participate in the survey was distributed to 2,990 dental health care workers in Sweden. Open-ended questions were analyzed using the Theoretical Domains Framework, closed-ended questions with Pearson's chi-squared test. RESULTS: The response rate was 41.7%. Of the respondents, 78.7% were ‘very satisfied’ or ‘fairly satisfied’ with the information they received. Conflicting messages were reported as a problem, especially regarding how highly prioritized the pandemic protocols were. ‘Fairly safe’ or ‘very safe’ were the responses chosen by 70.9%, while 54.2% recounted situations that made them feel unsafe. The sense of safety was mainly related to one’s own knowledge, self-perceived skills, and support in the workplace. The feeling of not being safe was foremost related to resources: primarily PPE shortages and time-related shortages. Respondents who reported being asked to forego surgical face masks and/or economize with gloves/hand rub because of shortages were more likely to have felt unsafe (p = .001). CONCLUSIONS: Most were satisfied with the information they had received, and most felt safe during the pandemic, but several respondents reported situations where they felt pressured to make compromises with their infection control. Future pandemic protocols should have ethics clearly incorporated regarding situations when there is a shortage of resources and include better planning for the provision of supplies for infection control

Endodontic follow-up practices, sources of knowledge, and self-assessed treatment outcome among general dental practitioners in Sweden and Norway

Objective: To reduce the gap between what can be achieved in endodontic treatments and the observed treatment outcome among general dental practitioners, the present study set out to assess the status of the endodontic practices as regards to knowledge and self-assessed skills among general dental practitioners in Sweden and Norway. Material and method: The questionnaire was sent to 1384 general dental practitioners. It contained questions regarding access to continuing education in endodontics, sources of knowledge for clinical management of patients, post-operative follow-ups, self-assessed success-rate, and the initial diagnosis impact on the outcome of endodontic treatments. Results: The response rate was 61.4%. Almost half estimated their endodontic success-rate to be 90%. About two-thirds of the respondents did not know, or did not believe, that the initial diagnosis could affect the outcome of their endodontic treatments. Respondents who did not believe the diagnosis could impact the outcome were more likely to estimate their success rate as the highest (p<.001). Less than half performed post-operative follow-ups a year after treatment. A third of the respondents had not attended any continuing endodontic education. Conclusion: Dentists who do not receive regular feedback on their treatments may lack insight into their own shortcomings. If this is combined with insufficient knowledge and understanding it may result in sub-par endodontic treatments being performed. It is important to have reliable ways to communicate current endodontic knowledge and to establish robust methods that may help dentists accurately assess their own performance in endodontics

Varje steg viktigt för optimalt behandlingsresultat

Ett lyckat resultat av en endodontisk behandling är starkt förknippat med väl utförda behandlingsmoment, från att arbeta aseptiskt till den slutliga permanenta restaureringen. A successful outcome of endodontic treatment is strongly associated with well-performed treatment procedures. A prerequisite for satisfactory treatment is access to the root canals via an adequate access cavity preparation that is correctly positioned, of suitable size, and with straight-line access to the canals. After gaining access to the root canals the root canal working length is determined by an electronic apex locator combined with radiographs, preferably after coronal flaring. The root canals are then cleaned and shaped, and in most cases rotary or reciprocating nickel-titanium instruments can be used. This is performed in conjunction with the use of an irrigation solution, usually a low concentration of sodium hypochlorite. Once the chemo-mechanical instrumentation has been thoroughly performed, filling of the root canals is the next essential step. A good quality root filling should end within 2 mm from the radiographic apex without any voids. This is of significant importance for a successful outcome of the treatment, while the materials and techniques appear less important. Lastly, the tooth should be permanently restored as soon as possible after the root filling, to prevent fracture and reinfection. Provided that the treatment procedures have been adequately performed, under aseptic conditions,  high success rates can be expected

Varje steg viktigt för optimalt behandlingsresultat

Ett lyckat resultat av en endodontisk behandling är starkt förknippat med väl utförda behandlingsmoment, från att arbeta aseptiskt till den slutliga permanenta restaureringen. A successful outcome of endodontic treatment is strongly associated with well-performed treatment procedures. A prerequisite for satisfactory treatment is access to the root canals via an adequate access cavity preparation that is correctly positioned, of suitable size, and with straight-line access to the canals. After gaining access to the root canals the root canal working length is determined by an electronic apex locator combined with radiographs, preferably after coronal flaring. The root canals are then cleaned and shaped, and in most cases rotary or reciprocating nickel-titanium instruments can be used. This is performed in conjunction with the use of an irrigation solution, usually a low concentration of sodium hypochlorite. Once the chemo-mechanical instrumentation has been thoroughly performed, filling of the root canals is the next essential step. A good quality root filling should end within 2 mm from the radiographic apex without any voids. This is of significant importance for a successful outcome of the treatment, while the materials and techniques appear less important. Lastly, the tooth should be permanently restored as soon as possible after the root filling, to prevent fracture and reinfection. Provided that the treatment procedures have been adequately performed, under aseptic conditions,  high success rates can be expected

Endodontic operative field asepsis : a comparison between general dentists and specialists

Objective: The aim was to evaluate the establishment of an aseptic endodontic operative field in general dentistry by assessing general dentists’ ability to reduce the amount of contamination to a non-cultivable level, and to compare the operative field asepsis at a general dentistry clinic with that at an endodontic specialist clinic. Materials and Methods: A total of 353 teeth were included in the study (153 in general dentistry, 200 at the specialist clinic). After isolation, control samples were taken, the operative fields disinfected with 30% hydrogen peroxide (1 min) followed by 5% iodine tincture or.5% chlorhexidine solution. Samples were collected from the access cavity area and buccal area, placed in a fluid thioglycolate medium, incubated (37°, 7 d), evaluated for growth/non-growth. Results: Significantly more contamination was observed at the general dentistry clinic (31.6%, 95/301), than at the endodontic specialist clinic (7.0%, 27/386) (p <.001). In general dentistry, significantly more positive samples were collected in the buccal area than in the occlusal area. Significantly more positive samples were collected when the chlorhexidine protocol had been used, both in general dentistry (p <.001) and at the specialist clinic (p =.028). Conclusions: The result from this study shows insufficient endodontic aseptic control in general dentistry. At the specialist clinic, both disinfection protocols were able to reduce the amount of microorganisms to a non-cultivable level. The observed difference between the protocols may not reflect a true difference in the effectiveness of the antimicrobial solutions, as confounding factors may have contributed to the result