Dr. Ruchika Roongta Nawal, Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, MAMC Complex, New Delhi - 110 002, India. E-mail: r_roongta@yahoo.com Date of submission : 11.03.2013 Review completed : 12.05.2013 Date of acceptance : 30.05.2013 Original Article A survey of attitude and opinions of endodontic residents towards regenerative endodontics Shivani Utneja, Ruchika Roongta Nawal, Mohammed Irfan Ansari 1 , Sangeeta Talwar, Mahesh Verma 2 Departments of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences and 1 Jamia Milia Islamia, Faculty of Dentistry, 2 Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India A b s t r a c t 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 INTRODUCTION 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 (REPs). [3-10] 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 REPs 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 Access this article online Quick Response Code: Website: www.jcd.org.in DOI: 10.4103/0972-0707.114357 Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics 315 Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 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 REPs. 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 REPs in the post graduate curriculum and alterations if any are required in the teaching curriculum of the residents pertaining to REPs. 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 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 REPs. 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 REPs 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 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 % (n) Profile of participants Specify your age Less than 35 100 (150) More than 35 0 (0) What is your sex? Male 41.3 (62) Female 58.6 (88) Indicate the location of your post graduate study North India 24.6 (37) South India 41.3 (62) East India 0.6 (1) West India 10 (15) Practiced hours per week Less than 20 h 6.6 (10) More than 20 h 93.3 (140) Knowledge, attitude and opinion towards REPs Have you ever received continued education in stem cells and/or regenerative dental treatments? Yes 50.6 (76) No 49.3 (74) Should regenerative therapy be incorporated into dentistry? Yes 86.6 (130) No 7.3 (11) May be 6 (9) Have you or any of your relatives used umbilical cord or other types of stem cell banking? Yes 14.6 (22) No 80.6 (121) Unsure 4.6 (7) Do you think that dental stem cell banking will be useful to be able to regenerate dental tissues? Yes 84.6 (127) No 4 (6) Unsure 11.3 (17) How many years do you think it will take for some regenerative stem cell therapies to be used in dentistry? 0-10 years 70.6 (106) 11-20 years 21.3 (32) More than 21 years 7.3 (11) Never 0.6 (1) How many years do you think it will take before dentists are able to implant new teeth grown in a laboratory? 0-10 years 36 (54) 11-20 years 41.3 (62) More than 21 years 20 (30) Never 2.6 (4) Would you be willing to attend a training course and/ or continuing education courses to apply regenerative dental treatments? Yes 88 (132) No 4 (6) Unsure 8 (12) What do you think would be the biggest obstacle to a patient accepting regenerative dental treatment? Higher cost 74.6 (112) Fear of stem cells 12 (18) Other reasons 13.3 (20) Would you be willing to save teeth and dental tissue for future regenerative dental treatment? Yes 87.3 (131) No 2.6 (4) Unsure 10 (15) Contd... Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 316 Table 1: Contd... % (n) Do you think that regenerative dental treatment will be a better treatment option than tooth implant placement? Yes 83.3 (125) No 4 (6) Unsure 12.6 (19) Do you think stem cells and regenerate treatments should be tested on animals prior to clinical testing? Yes 83.3 (127) No 5.3 (8) Unsure 10 (15) Do you believe that dental professional associations should regulate the use of stem cell and regenerative dentistry? Yes 85.3 (128) No 6.6 (10) Unsure 8 (12) Clinical application of REPs Do you use any type of regenerative procedures in your practice, such as membranes, scaffolds or bioactive materials? Yes 52.6 (79) No 47.3 (71) What is your assessment of regenerative dental treatment outcomes? Successful 46.6 (70) Unsuccessful 8 (12) Dont know 45.3 (68) After nonsurgical root canal treatment, would the healing of periapical tissues be enhanced by tissue engineering? Yes 77.3 (116) No 3.3 (5) Dont know 19.3 (29) Which of the following regenerative endodontic treatments is the most valuable? Healing of periradicular bone 8.6 (13) Continued root development in immature teeth 9.3 (14) Pulp tissue revitalization within a root canal 20 (30) Tooth re-implantation 2 (3) All of the above 60 (90) What percentage of cases in your practice involves necrotic immature teeth? Less than 10% 22 (33) 11-25% 48 (72) 26-50% 20 (30) More than 50% 10 (15) What percentage of cases in your practice involves avulsed or traumatized teeth? Less than 10% 54 (81) 11-25% 28.6 (43) 26-50% 14 (21) More than 50% 3.3 (5) What percentage of cases in your practice involves periradicular lesions? Less than 10% 10 (15) 11-25% 22.6 (34) 26-50% 38.6 (58) More than 50% 28.6 (43) What do you consider to be the optimal treatment for necrotic immature teeth? Calcium hydroxide apexification 3.3 (5) Calcium hydroxide application followed by MTA apical plug and backfilling with obturation material 54 (81) MTA apical plug and back-fill with obturation material 25.3 (38) Tribiotic paste and pulpal regeneration 17.3 (26) Contd... Table 1: Contd... % (n) Wo'uld you be willing to collect dental tissue for stem cell banks? Yes 76.6 (115) No 5.3 (8) Unsure 18 (27) What should the cost for regenerative dentistry be? Equal to current treatment 28.6 (43) More than current treatment 50.6 (76) Less than current treatment 6 (9) Unsure 14.6 (22) What would make you most likely to recommend stem cell and regenerative dental treatments to your patients? If it is the most effective treatment option 53.3 (80) It is safe and reliable 40 (60) If it is the most cost-effective option 6 (9) I would never recommend it 0.6 (1) RPEs: Regenerative endodontic procedures, MTA: Mineral trioxide aggregate Prole 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 REPs 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 REPs. Two third of participants (74.6%) thought the greatest obstacle to a patient accepting REPs 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 REPs. Three fourth of participants (83.3%) thought that REPs could be a more successful treatment than implants, (12.6%) were unsure, and remaining (6%) of the participant didnt consider that REPs could be a Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics 317 Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 better treatment than implant. Majority of participants (83.3%) were of the opinion that REPs 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 didnt want regulation and (8%) were unsure. Clinical application of REPs 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 REPs 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 REPs. (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 REPs 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 REPs 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 REPs 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 REPs should be more than current treatment. The majority of participants (53.3%) would recommend stem cell treatment and REPs to their patients if it was the most effective treatment option. DISCUSSION 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 REPs 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 REPs and preferred it over implants as a treatment option, However, almost all felt a need to attend training in REPs, reflecting an underlying lack of knowledge. According to the majority of respondents another prerequisite to carry out REPs 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 REPs 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, REPs should be priced such that it is equally affordable to patients as other standard procedures. Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 318 In clinical practices, almost half of the residents were doing some type of REPs, 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 REPs 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 REPs in addition to these guidelines to protect patients and health care providers. CONCLUSION The survey participants expressed general optimism and at the same time showed a consensus on the need for research and training towards REPs. An impending need was felt amongst the residents for ethical regulation of REPs 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 REPs worldwide. ACKNOWLEDGMENT 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 1. Saber SE. 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