1http://dx.doi.org/10.20396/bjos.v16i0.8650494 Volume 16 2017 e17045 Original ArticleBJOS Current trends in technological armamentarium and treatment among Brazilian endodontists Ana Cristina Garcia Ferreira1 Marcos Frozoni2, Maíra Prado3, Brenda Gomes4, Fernanda Signoretti5, Adriana De-Jesus-Soares6. Correspondence: Dr Maira do Prado Praça da Bandeira, 149 - Praça da Bandeira, Rio de Janeiro - RJ, postal code 20270-150– Brazi Phone/ Fax: (0055) (21) 2502-3238 E-mail: maira.prado@uva.br Received: May 6, 2017 Accepted: August 09, 2017 1 Post graduate Student, São Leopoldo Mandic Dental Research Center, Campinas, São Paulo, Brazil. 2 PhD, Professor, São Leopoldo Mandic Dental Research Center, Campinas, São Paulo, Brazil. 3 PhD, Professor, Department of Res- torative Dentistry, Veiga de Almeida University, Rio de Janeiro, RJ, Brazil. 4 PhD, Professor, Department of Res- torative Dentistry, Piracicaba Dental School, State University of Campinas- UNICAMP, Piracicaba, SP, Brazil. 5 PhD, Professor, São Leopoldo Mandic Dental Research Center, Campinas, São Paulo, Brazil. 6 PhD, Professor, Department of Res- torative Dentistry, Piracicaba Dental School, State University of Campinas- UNICAMP, Piracicaba, SP, Brazil. Aim: To determine the current trends in technological armamen- tarium and endodontic treatment among Brazilian endodontists. Methods: A total of 279 endodontists answered a web-based sur- vey questionnaire about their region of activity in Brazil and years as a specialist, average number of endodontic cases treated per month, number of visits to complete the treatment, use of rubber dam for isolation, type of irrigant, obturation technique and device used for this purpose, temporary filling materials, and greater diffi- culty encountered during treatment and technological armamenta- rium. A descriptive analysis, expressed in terms of frequency and percentage, was performed and the data were correlated using the chi-square test (p<0.05). Results: Most of the respondents had up to 10 years as specialists. More than 50% of endodontists preferred to complete the endodontic treatment in a single visit. Ninety-nine percent of endodontists used rubber dam for isolation. NaOCl was the most widely used irrigant. Most of the respondents associated different techniques for root canal filling. Lateral condensation and Continuous wave of condensation were the isolated technique most reported. Filling devices (thermocompactors) were used by 53% of endodontists. Glass ionomer was the preferred temporary filling ma- terial. The answers for the use of technological armamentarium re- vealing that 94% of endodontists used an apex locator; 67.38% utili- zed magnification (loupe: 23.66%; microscope: 35.48%; microscope and loupe: 8.24%); 58% reported to digital radiography; and 47.31% used computed tomography as a complementary tool. About me- chanized instrumentation, 44.44% endodontists employed rotary and reciprocating files. The difficulties encountered during endodon- tic treatment were classified as preparation > access > obturation > anesthesia > isolation. Conclusions: Most endodontists have im- plemented new technologies, such as mechanical instrumentation, apex locators, magnification, digital radiography, computed tomo- graphy, ultrasound, and obturation tools, in their clinical practice. Keywords: Endodontics. Root Canal Irrigants. Root Canal Obturation. Root canal therapy. Trends. mailto:ajsoares.endo@uol.com.br 2 Ferreira et al. Introduction In the last decades, new trends and technologies in dentistry, specifically in endodon- tics, have been introduced in the clinical practice of specialists and general practitio- ners, providing benefits to the quality, efficiency, and safety of endodontic treatment1,2. Technological innovations such as apex locator, electric motor with controlled speed and torque, nickel titanium files, irrigation systems, ultrasound, clinical microscope, thermoplastic filling devices, digital radiography, and computed tomography have brought about a revolution in endodontic treatment1-4. These new technologies and materials have allowed obtaining a more accurate working length and root canal patency, with consequently better preparation and filling, contributing to better predictability of endodontic treatment5,6. Additionally, the length of treatment was reduced. According to Bjørndal and Reit7, in the past, con- ventional endodontic treatments were performed in five, six, or up to seven sessions. With technological advancements, the number of sessions declined and endodontic treatment is usually performed in a single session. Questionnaires to assess trends in endodontic treatment and new technologies are commonly applied in other countries8-18. In Brazil, in 1999, Gurgel-Filho et al.19 con- ducted a study on the philosophy of single-session endodontic treatment in Brazilian and North American universities. Afterwards, in 2001, Santos et al.20 evaluated the conception of endodontists regarding new technologies and teaching in the area. The most recent study found in the literature dates back to 2011, when Pedrosa et al.21 evaluated the panorama of tooth isolation in dental clinics in Belo Horizonte. In view of the new technologies incorporated into the endodontic arsenal in recent years and the limited knowledge about endodontic treatment trends in Brazil, the pre- sent study aimed to determine the current trends in technological armamentarium and endodontic treatment among Brazilian endodontists. Material and MethodS This study was approved by the local Research Ethics Committee (Protocol no. 47780415.2.0000.5374). An invitation to participate in a web-based survey was sent to members of the Brazilian Forum on Endodontics (http://www.forumdeendodontia.com.br), an online group of clinical specialists and researchers in endodontics. A total of 2,000 endodontists from the southeast, south, and northeast regions of Brazil were invited to participate. These regions were selected because, according to the Brazilian Federal Dental Council, they concentrate the largest number of endodontists. The survey consists of a questionnaire with 17 multiple-choice questions with multiple selections about region of activity in Brazil and years as a specialist, average number of endodontic cases treated per month, number of visits to complete the treatment, use of rubber dam for isolation, type of irrigant, obturation technique and device used for this purpose, temporary filling materials, and greater difficulty encountered during treatment and technological armamentarium (use of apex locator, mechanized instrumentation, 3 Ferreira et al. magnification, digital radiography, cone beam computed tomography (CBCT), and ultra- sonic system). The questionnaire (translated into English) is shown in Table 1. Table 1. Questionnaire 1. Region of activity 2. Years of activity as a specialist 3. On how many teeth do you perform endodontic treatment on a monthly basis? ( ) Northeast ( ) 1-5 years ( ) 1-10 ( ) Southeast ( ) 6-10 years ( ) 11-20 ( ) South ( ) 11-15 years ( ) > 20 ( ) 16-20 years ( ) 21-25 years ( ) 26-30 years ( ) > 30 years 4. In how many sessions do you perform endodontic treatment? 5. Do you use rubber dam for tooth isolation? 6. Why do you not use rubber dam for tooth isolation? ( ) One visit ( ) Yes ( ) Difficulty ( ) Multiple visits ( ) No ( ) Cost ( ) Mostly in one visit ( ) Delay ( ) Mostly in multiple visits 7. Which irrigant(s) do you use? 8. Which obturation technique(s) do you use? 9. Do you use any filling device (thermocompactor)? ( ) Sodium hypochlorite ( ) Lateral Condensation ( ) Yes ( ) Saline ( ) Schilder technique ( ) No ( ) Distilled water ( ) Continuous wave of condensation (Buchanan) ( ) Anesthetic ( ) Mcspadden technique ( ) Hydrogen peroxide ( ) Tagger’s hybrid technique ( ) EDTA ( ) Other ( ) 2% chlorhexidine gel ( ) Combination of two irrigants ( ) Other 10. What material(s) do you use for temporary sealing after endodontic treatment? 11. Do you use an apex locator? 12. Do you use ultrasound? ( ) IRM ( ) Yes ( ) Yes ( ) Zinc oxide/eugenol ( ) No ( ) No ( ) Glass ionomer ( ) Composite resin ( ) Temporary restorative material (Coltosol) 13. Do you use magnification? 14. Do you use digital radiography? 15. Do you use routine exams such as cone beam computed tomography to aid in the diagnosis? ( ) Microscope ( ) Yes ( ) Yes ( ) Loupe ( ) No ( ) No ( ) No 16. Do you use mechanized instrumentation? 17. Which step(s) is(are) most difficult during endodontic treatment? ( ) Rotary techniques ( ) Anesthesia ( ) Reciprocating techniques ( ) Access ( ) Oscillating techniques ( ) Isolation ( ) No ( ) Preparation ( ) Obturation 4 Ferreira et al. The survey was closed 3 months after the questionnaire was sent. Data were collec- ted, exported to Excel (Microsoft, Seattle, USA), and analyzed by the IBM SPSS 2.1 software. A descriptive analysis, expressed in terms of frequency and percentage, was performed and the data were compared using the chi-square test (p<0.05). RESULTS A total of 279 complete questionnaires were received (response rate of 13.95%). Figure 1 showed the region of activity and years of activity as specialist of the respon- dents. The most of respondents work in the southeast region. With respect to years of activity as a specialist, it was ranked as: 1-5 years > 6-10 years > 11-15 years > 16-20 years > 21-25 years > 26-30 years = >30 years. Most respondents (61.75%) had up to 10 years’ experience as endodontists. Regarding the number of monthly endodontic treatments, most specialists (82%) tre- ated more than 11 teeth. As to the number of visits to conclude the treatment, it was ranked as: mostly in one visit > mostly in multiple visits > only in single visit > only in multiple sessions (Figure 2). Regarding rubber dam for tooth isolation, 99% of respondents said they used it. The remaining 1% who did not use it reported it was either due to the cost or time required for isolation (treatment delay). Figure 1. Percentage of respondents according to their region of activity and years as a specialist. Region of activity (%) Years of activity as specialist (%) Northeast Southeast South 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years 26-30 years 63.44 20.79 13.98 8.24 6.09 5.02 5.02 40.86 20.7915.77 Figure 2. Number of monthly endodontic treatments and number of visits to conclude the treatment (%). Number of endodontic tratment performed per month (%) Years of activity as specialist (%) 1-10 11-20 > 20 One-visit Multiple-visit The most in one-visit The most in multiple-visit 33 53.05 23.66 15.77 7.53 18 49 5 Ferreira et al. Concerning irrigants (Table 2), they were ranked as: NaOCl/EDTA > others > only NaOCl > NaOCl/ EDTA/ 2% CHX gel/ saline solution > NaOCl/ EDTA/ 2% CHX gel = NaOCl/ EDTA/saline solution > saline solution/ EDTA/ 2% CHX gel > saline solution/2% CHX gel = only 2% CHX gel > saline solution. The techniques for root canal filling, used either in isolation or combined, are displayed in Table 3. The most of participants associated different techniques. Lateral condensa- tion and continuous wave of condensation (Buchanan) were the techniques most cited in isolation. Filling devices (thermocompactors) were used by 53% of endodontists. Regarding temporary sealing materials after endodontic treatment, 20.07% of the respon- dents used only glass ionomer, 17.56% used only provisional restorative material (Coltosol®), 17.20% participants answered others, 16.13% used composite resin only; 10.75% used glass ionomer and Coltosol®; 8.24% used glass ionomer and composite resin; 6.09% used composite resin and Coltosol®; 2.87% used IRM and 1.08% Zinc oxide/eugenol. The answers for the use of technological armamentarium revealing that 94% of endo- dontists used an apex locator; 67.38% utilized magnification (loupe: 23.66%; micros- cope: 35.48%; microscope and loupe: 8.24%); 58% resorted to digital radiography; and 52.69% did not use computed tomography as a complementary tool. Table 2. Irrigants used in isolation or combined. Irrigants used isolated and in association. Number of respondents (%) 2% CHX gel 12 (4.30%) NaOCl 55 (19.71%) NaOCl/ EDTA 69 (24.73%) NaOCl/ EDTA/ 2% CHX gel 17 (6.09%) NaOCl/ EDTA/ saline solution 15 (5.38%) NaOCl/ EDTA/ 2% CHX gel/ saline solution 26 (9.32%) saline solution 1 (0.36%) saline solution/2% CHX gel 12 (4.30%) saline solution/ EDTA/ 2% CHX gel 15 (5.38%) Others 57(20.43%) Total 279 (100%) Table 3. Root canal filling techniques used either in isolation or combined. Root canal filling techinique Number of respondents (%) Lateral condensation 34 (12.19%) Tagger’s hybrid technique 23 (8.24%) Mc Spadden 19 (6.81%) Continuous wave of condensation (Buchanan) 34 (12.19%) Schilder 24 (8.60%) Other 57 (20.43%) Associations 88 (31.54%) Total 279 (100%) 6 Ferreira et al. About mechanized instrumentation, 44.44% employed rotary and reciprocating files; 3.94% associated rotary and oscillating tools; 14.7% associated rotary, reciprocating, and oscillating tools; 28.32% used only rotary instruments; 5.73% used only reciproca- ting instruments; 1.43% utilized only oscillating files; and 1.43% did not use mechani- zed instrumentation at all. The difficulties encountered during endodontic treatment were classified as prepara- tion (44.8%) > access (22.94%) > obturation (13.98%) > anesthesia (9.32%) > isolation (2.15%). More than one item was reported as a difficulty by 6.81%. There was statistical difference in mechanical instrumentation across different regions (p = 0.009). All respondents from the south of Brazil reported using some type of mecha- nical instrumentation compared with the southeast and northeast where a small percen- tage (1.7%) did not use any mechanical instrumentation. In the south, there was a higher percentage (29.5%) of professionals who combined rotating, oscillating, and reciprocating instruments compared to 15.5% in the northeast and only 10.7% in the southeast. On the other hand, in the association of rotary and reciprocating tools, there was a lower percen- tage in the south (29.5%) than in the southeast (48%) and northeast (44.8%) regions. A statistical difference was observed between the use of digital radiography and time of activity as a specialist (p = 0.000). Among endodontists with 1 to 5 years’ expe- rience, 74.5% did not use digital radiography, and among those with 11 to 15 years of practice, 61.5% used it. However, among endodontists with over 21 years of expe- rience, the use of digital radiography was greater than 50%. Years as a specialist significantly influenced (p = 0.007) the use of CBCT. With up to 10 years of practice, most endodontists did not use CBCT as a complementary tool, but there was a predominance of CBCT use between 16 and 30 years of practice. Among endodontists who used digital radiography, 60.5% utilized CBCT as a comple- mentary tool – which was statistically significant (0.000). The number of years as a specialist influenced the use of magnification (p = 0.021) and ultrasound (p = 0.021). As time as a specialist increases, endodontists use more magnification and ultrasound. When comparing mechanical instrumentation and magnification, four endodontists did not use mechanical instrumentation and also did not adopt any type of magnifi- cation. Among those who used rotary tools, 24.1% used a microscope, 10.1% micros- cope and loupe, 13.9% loupe, and 51.9% did not use any magnification. Discussion A questionnaire was employed in the present study to identify the materials and tech- niques most widely used in endodontics as well as the new technologies and trends incorporated into the daily practice of Brazilian endodontists. Most respondents had 1 to 5 years’ experience whereas quite a small number had 26 to 30 years or more of practice. This finding is consistent with that of other studies conduc- ted elsewhere1,10,22. However, Lee et al.4, in the United States, and Slaus and Bottenberg18, in Belgium, observed the highest number of professionals with 11 years or more of clini- cal practice, while Whitten et al.23 showed similar percentages for all groups. 7 Ferreira et al. Regarding the number of monthly endodontic treatments, almost half of the endodon- tists treated 20 teeth or more. Locke et al.15, after evaluating general practitioners in Wales, observed that 83% of them performed endodontic treatment on 1 to 5 teeth every week, totaling 5 to 20 teeth per month. Savani et al.17 showed that most general practitioners (58%) treated 1 to 5 teeth and that only 2% treated more than 20 teeth per month. The difference in the results may be due to the professionals evaluated. In the present study, only endodontists answered the questionnaire while in other studies, general practitio- ners were also evaluated. The present study indicates that the monthly number of teeth treated by endodontists exceeds the number of teeth treated by general practitioners. Concerning the number of sessions required to complete endodontic treatment, the most of respondents said they performed most of the treatments in a single visit in accordance with Savani et al.17 who observed that most interviewees preferred to per- form the treatment in a single session (63%) and only 21% in multiple sessions. Pre- ference is related to the shorter length of treatment after the advent of nickel titanium files. However, other authors7,12,18,22 found that most of the surveyed dentists preferred multiple endodontic treatment sessions. Whitten et al.23 argue that specialists opted for a single session while general practitioners preferred multiple sessions. With respect to tooth isolation, in the present study, 99% of endodontists used a rub- ber dam, a superior incidence than found by Zou et al.1 and Whitten et al. 23. Also, these studies1,23 observed that the percentage of specialists who used a rubber dam during endodontic practice was higher than that obtained for general practitioners. Additio- nally, other previous studies7,10,11-13,18,22 that evaluated general practitioners observed that the most of them did not use rubber dam routinely during root canal treatment. The reasons why some participants did not to use a rubber dam included treatment delay and costs, as described in the present study. As to the types of irrigants, most professionals used NaOCl and a combination of sodium hypochlorite and EDTA. Compared with other studies, sodium hypochlorite is, in fact, the most widely used irrigant in most countries9,11,23. Gurgel Filho et al.19 obser- ved that EDTA was employed in 67% of Brazilian dental schools universities against only 8% in the United States. However, sodium hypochlorite at higher concentrations (2.5% to 5.25%) was more widely used in the United States (94%) than in Brazil (43%). In countries such as India10 and Saudi Arabia12, saline solution is far more common than sodium hypochlorite. In Nigeria22, the use of saline solution (28.8%) is similar to that of sodium hypochlorite (32.5%). Regarding root canal filling, a great variation was observed in the combination of tech- niques, revealing the use of heterogeneous protocols by Brazilian specialists. Lateral condensation and continuous wave of condensation were the most frequently adop- ted techniques isolated, in accordance with Lee et al. 4 findings in the United States. Other studies, in Denmark7 and in north of Saudi Arabia12 revealed that lateral conden- sation was the most commonly used technique. In the present study, endodontists preferred glass ionomer, followed by temporary res- torative material (Coltosol®) and composite resin as temporary sealing materials. Other professionals employed more than one material. Slaus and Bottenberg18 and Lee et al.4 showed that provisional restorative material Cavit® was the material of choice, followed 8 Ferreira et al. by IRM® and zinc oxide eugenol cements. Gupta and Rai10 also described extensive use of Cavit® and eugenol zinc oxide cement. Kaptan et al.13 also found that Cavit® was the preferred, followed by zinc phosphate cement, and zinc oxide eugenol and IRM® cements. Composite resin was not cited as a temporary restorative material. Among technological innovations, an apex locator was widely employed by the res- pondents. This percentage was significantly higher than that reported in previous stu- dies1,4,11,22. This can be explained because the present study evaluated endodontists participating in a forum that discusses innovations and exchanges of experiences in endodontic practice. Also, the difference can be associated with the culture, the aca- demic formation (in the graduation), the socioeconomic condition found among the dentists of different countries. Additionally, according to scientific evidence, previous studies report increasing use of this tool, as it provides greater accuracy in the deter- mination of working length and a decrease of operative time5,6. Regarding magnification, 23.66% of the endodontists used a loupe, 35.48% adopted the clinical microscope, 8.24% associated the microscope with a loupe, and 32.62% did not use any magnification instrument. Kersten et al.14 showed that the use of mag- nification accounted for 90% while in 1999 it was only 52%. When compared with the present study, their rate was higher than that obtained here. By evaluating different groups, the use of the clinical microscope as a function of years of activity was 22.8% in the group with 1-5 years’ experience and 43.6% among those with 11-15 years of practice. Endodontists with 16-20 years of activity were those who used magnifica- tion most frequently (65.2%). The findings also show that the adoption of new tech- nologies by the professionals requires a certain time of activity, continuing education and training, with a long learning curve10,12. Digital radiography is a faster, non-polluting method that provides less radiation expo- sure5. In this study, it was employed by 42% of the endodontists. Gupta and Rai10, in India, observed that digital radiography was used by 17% of the respondents and a significan- tly higher proportion of respondents had postgraduate qualifications as compared to respondents who did not have postgraduate qualifications. Savani et al.17, in USA, found that 72% of general dentists used this technological innovation. The difference in the results can be associated with the culture, the academic formation (in the graduation) and the socioeconomic condition found among the dentists of different countries In the present study, most specialists used mechanical instrumentation, choosing more than one system. In most recent surveys, the results vary across countries. In Nigeria22 and in Saudi Arabia12, the use of mechanical instrumentation is low (2.5% and 17.5%, respectively). In India10 and in Turkey13, the utilization of nickel titanium files accounts for 61% and 43.9%, respectively. In the United States17 and in Wales15, the rate is higher (74% and 71%, respectively), even among general practitioners. The use of rotary instrumentation associated with some other type (oscillating, reci- procating, or both) demonstrated a significant increase in the number of teeth tre- ated per month. In the present study, endodontists who used manual instrumenta- tion answered to treat a maximum of 10 teeth per month while those who employed mechanical instrumentation treated, on average, 11 teeth or more. Those who combi- ned different types of instrumentation treated 20 teeth or more. Our study consolida- tes the literature findings about the efficiency and speed of mechanical systems5,24,25. 9 Ferreira et al. A positive correlation was observed between mechanical instrumentation and magnifi- cation. These findings indicate that professionals working with varied instrumentation systems are more prone to implement technological innovations in their clinical practice. Regarding the greatest difficulties encountered during endodontic treatment, preparation was mentioned by 44.8%, access by 22.94%, obturation by 13.98%, and anesthesia by 9.32%. These findings are consistent with those of other studies, such as the one con- ducted by Udoye et al.22, who detected difficulties in access and preparation among Nige- rian dentists, leading to a high rate of perforations. Gupta and Rai10 and Hommez et al.11 suggested continuing education and training as ways to solve these problems. In conclusion, most endodontists affiliated with the Brazilian Forum on Endodontics from the southeast, south, and northeast regions of Brazil have implemented new technologies, such as mechanical instrumentation, apex locators, magnification, digital radiography, computed tomography, ultrasound, and obturation tools, in their clinical practice. More than 50% of endodontists preferred to complete the endo- dontic treatment in a single visit. Ninety-nine percent of endodontists used rubber dam for isolation. NaOCl was the most widely used irrigant. Most of the respon- dents associated different techniques for root canal filling. Lateral condensation and Continuous wave of condensation were the isolated technique most reported. Glass ionomer was the preferred temporary filling material. The most of endodon- tists used an apex locator; 67.38% utilized magnification (loupe: 23.66%; micros- cope: 35.48%; microscope and loupe: 8.24%); 58% reported to digital radiography; and 47.31% used computed tomography as a complementary tool. The difficulties encountered during endodontic treatment were classified as preparation > access > obturation > anesthesia > isolation. References 1. Zou H, Li Y, Lian X, Yan Y, Dai X, Wang G. Frequency and Influencing Factors of Rubber Dam Usage in Tianjin: A Questionnaire Survey. Int J Dent. 2016;2016:7383212. doi: 10.1155/2016/7383212. 2. Lababidi EA. 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