Choice of Restorative Material for Endodontically Treated Teeth in Teaching Institutions of Multan

INTRODUCTION

The endodontic and restorative dentistry is the study of preservation of natural tooth structure. Endodontic treatment is required for grossly carious, fractured or badly broken down vital or non-vital teeth.1

The loss of tooth structure in endodontic treatment due to caries or endodontic procedure increases the vulnerability of the tooth to fracture. The longevity of such teeth rely on the amount of tooth loss and the ability of restorative material to replace the missing tooth structure.2

It requires distinctive consideration where there is extensive loss of tooth structure. In addition, the prognosis of endodontically treated tooth (ETT) depends upon multiple criteria such as the amount of remaining tooth structure3, type of final restoration, design of the post, and type of core build-up material used.4

There is general concept that endodontic treatment failure might be due to restoration failure , therefore selection of restorative material, technique and time of restoration are significant factors.5

It is further suggested that appropriate and early permanent restoration after completion of endodontic treatment should be carried out. When temporary filling is followed by permanent restoration to seal the access cavity, there are more chances of leakage and bacterial invasion.6

There are more chances of leakage and bacterial invasion when temporary filling is followed by permanent restoration to seal the access. Endodontically treated teeth having permanent restoration are more successful as compared to temporary restoration.6-8

A core build-up is a restoration that is used to restore the coronal portion of the badly broken down tooth. As core build-up material restores large bulk of missing tooth structure and resists multidirectional chewing forces for many years, it’s compressive and tensile strength are important factors for better prognosis of ETT.9

To enable the retention of core build-up material, they are usually reinforced by pins, post and bonding system. A dental post is a material placed in the root of a structurally insufficient tooth to provide additional retention and support the coronal restoration. The post should provide this support without increasing the risk of root fracture.10

A number of dental materials have been used for core build-up.11 They are direct and indirect material namelypin retained restoration and prefabricated post or custom made post and core respectively.12 The material used as core build-up includes amalgam, glass ionomer cement, resin modified glass ionomer cement, cermet and composite resin. Composite resin is mostly used to build-up the core of the missing tooth.12 For restoration of ETT different procedures have been recommended. These treatment procedures include the use of post and core, partial or full crowns, and direct resin composite or amalgam fillings. The available post and core systems are custom made and pre-fabricated. When the coronal tooth structure is insufficient to retain a core buildup then posts are recommended. The endodontically treated tooth can be used as abutment but there were chances of fracture of those ETT that had post and were terminal abutments.13 The clinical success of ETT is significantly increased with coronal coverage.14

It has been found that ETT without coronal coverage failed six times greater than crowned teeth.15 The prognosis of posterior ETT is considerably increased with crowning, however in anterior ETT crowning has not much significance.15

To assess and understand treatment approaches for ETT restorations, surveys are important tools.12 Several survey based studies have been published regarding restoration of ETT. However, the preference and strategies of dental practitioners in teaching institutes of Multan need to be investigated. The purpose of this study was to analyze the preference, techniques.

METHODOLOGY

A cross-sectional study was performed from 22nd to 28th October, 2019 in three teaching institutes of Multan; Nishter institute of dentistry (NID), Bakhtawar Amin medical and dental college (BAMDC) and Multan medical and dental college (MMDC). Non-probability convenience sampling was done in this survey. The total population of registered dentists working in above mentioned institutions was 160. Questionnaires were distributed among them.

The number of recovered questionnaires was 148 bringing the response rate to 92.5%. The calculated sample size for the total population of 160 was 114 according to Raosoft sample size calculator by keeping the confidence level 95%. Data were collected non-specifically using a fifteenquestion survey questionnaire. Questionnaire comprised of questions regarding clinician’s demographics (designation, area of interest/expertise and clinical experience), endodontic procedure preference, choice of material for core build-up, type of post, preference ofcrowning and type of crown material preferred. The collected data were analyzed and interpreted using SPSS version 22. The association between designation of the clinicians and rest of the variables mentioned above was analyzed using Pearson’s chi-square test. A significance level of p < 0.05 and confidence level of 95% was used.

RESULTS

From the population of dentists (160) working in the targeted institutions, 148 participated in the study (n=140). The data missed was 7.5 % due to no return of the questionnaire and absence of the participants from the workplace. Among the respondents having experience greater than 10 years were 26%, those having less than10 years were 25% and less than 5 years were 97%. The working place of the participants was 54.7 % at public place, 30.4 % at private and 14.9 % were at both places.

Postgraduate participants were 31.1 % while 68.9 % were graduates. The frequencies and percentages of studied variables are shown in Table 1.

Table 1: The frequencies and percentages of studied variables

Table 2: Association of experience with crown material and buildup time with place of working

Table 3: Association of post-graduation with endo-post type and crowning ETT

There was a statistically significant association between the restoration times of ETT and work place, given in the Table 2. The participant who were in public place opted “restoration after one week” significantly more than those working at private places (p = 0.002). Majority of participants (62%) had chosen endopost in ETT and prefabricated post were preferred over custom made post (p = 0.003) given in the table 3. Most of the participants (85.6%) preferred such tooth should be crowned (p = 0.39) shown in table 3. The respondents who had more than ten years of experience (76%) preferred PFM crown (p = 0.001) given in table 2.

DISCUSSION

This survey was conducted to know the recent preferences of core build-up and crown material for ETT in teaching institutes of Multan. According to the results of this survey-based investigation, the majority of the participants preferred amalgam as core build-up material on the basis of strength. Amalgam as a core build-up material was also popular in the United Kingdom.15 This may be due to amalgam isn’t considered as health hazard in many part of the world and is cost effective.

There was significant association between the build-up time of restoration and workplace of practioners (p = 0.002). Majority of the participants working in public place preferred restoration of ETT one week after obturation followed by after one day and immediate, in a sequence. The reason behind this might be the clinical and radiographic evaluation of ETT after one week as observed in a previous study. 17 The participants working in private place preferred immediate final restoration of ETT over one day and one week. The reason behind this might be to save the time and to avoid coronal leakage leading to failure of endodontic treatment which may occur in immediate temporary restoration, supported by previous studies. 18,19

According to the results, the majority of the participant (62%) had chosen endopost in ETT and prefabricated post were preferred over custom made post, which relates with the observations of other similar studies.20,21 The association between endopost type and post-graduation was significant (p= 0.003), 67% of those who had done post-graduation preferred prefabricated post over custom made post. This

trend might be due to fact that prefabricated post are easy to use and can be completed in single visit, so its time saving procedure. Most of the participants believed that core buildup material with endopost should be used as it decreases the chance of tooth fracture. This finding was in accord with dental practitioners practicing in Sweden, Germany and the United States . 10,22-24 Regarding the crowning of ETT having core build-up, 85.6% of participants opted such tooth should be crowned.

This may be due to the fact that ETT are more prone to fracture than vital teeth and crowning increases their strength and prognosis. Findings of present study are in agreement with previous studies. 15,25,26 The choice of PFM crown increased significantly with the increase in experience (p = 0.001). The highest preference of PFM was by those who had experience more than ten years (76%). The preference of PFM might be due to the fact that it has better strength to withstand the multidirectional chewing forces especially in molars and it has long term survival. 27 PFM crowns have good mechanical properties, adequate

esthetic results, and an acceptable biological status needed for periodontal health. 27

This study revealed that amalgam was preferred as core build-up material on the basis of strength. Endo-post was preferred for ETT in order to avoid fracture28 and majority of the participants preferred PFM as crown material in ETT. Furthermore, it was observed that PFM was more popular among dentist in teaching institutes of Multan, irrespective of their post-graduation qualification and work place.

CONCLUSION

Within the limitation of this study, the following conclusion can be drawn;

1. Amalgam was selected as core buildup on the basis of strength.
2. Most of the participants in the present study opted restoration of ETT after one week.
3. Endo-post was preferred by majority of the survey dentist.However, prefabricated post was preferred over custom made on the basis of ease of use and completion in single visit.
4. For crowning of ETT, majority of practitioners irrespective of their clinical experience and post-graduation qualification believed that ETT should be crowned for better prognosis, and PFM was the material of choice for the purpose.

CONFLICT OF INTEREST

None declared

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