1 Volume 22 2023 e233938 Original Article Braz J Oral Sci. 2023;22:e233938http://dx.doi.org/10.20396/bjos.v22i00.8673938 1 Assistant Professor, Science of Dental Materials, University College of Medicine and Dentistry, University of Lahore, Lahore, Pakistan. 2 Post Graduate Resident, Department of Operative Dentistry, Institute of Dentistry, CMH Lahore Medical College, NUMS, Lahore, Pakistan. 3 Post Graduate Resident, Department of Operative Dentistry, de ’Montmorency College of Dentistry, Lahore, Pakistan. 4 Demonstrator, Department of Operative Dentistry, Institute of Dentistry, CMH Lahore Medical College, NUMS, Lahore, Pakistan. 5 Assistant Professor, Periodontology Department, Institute of Dentistry, CMH Lahore Medical College, NUMS, Lahore, Pakistan. Corresponding author: Dr. Hammad Hassan Address: Science of Dental Materials, University College of Medicine and Dentistry, University of Lahore, Lahore, Pakistan. Email: hammadhassanh@gmail.com Phone: +92314-7991624 Editor: Dr. Altair A. Del Bel Cury Received: July 7, 2023 Accepted: October 6, 2023 Endodontic file separation and its management among dentists in Punjab, Pakistan: a cross-sectional study Hammad Hassan1* , Syed Moiz Ali2 , Baneen Khawar2 , Sidra Riaz3 , Razia Zia4 , Marij Hameed5 Aim: The study aimed to find the incidence and awareness of endodontic instrument separation and its management among dental house officers, postgraduate trainees, demonstrators, consultants, and general dentists. Methods: This online questionnaire-based cross-sectional study was conducted with the approval of the IRB in private and public dental hospitals and dental clinics in Punjab. The authors developed the survey tool, which comprises 24 closed-ended items regarding demographics, the incidence of file separation, and awareness about its management. The data were analyzed using IBM SPSS version 24. The Chi-Square Test was used to compare percentages of categorical variables. Results: Postgraduate trainees experienced the most instrument separations (43.6%), made the most retrieval attempts (49.2%), and experienced the most secondary errors during retrieval (52.1%) (p<0.001). Around four out of ten respondents always informed the patients (39.6%) and department (41.6%) about errors. Manual files (69.8%), stainless steel files (75.8%), and short files (60.4%) were more frequently separated, and the most frequent cause was older fatigue files (57.7%). Manual files were more frequently broken in public dental institutes (p=0.003). Two-thirds of the file separations (72.5%) occurred during cleaning and shaping in the apical third of molars (65.1%), especially in mesiolingual canal (56.4%). Bypass attempt was the most common in symptomatic teeth (47.7%). Conclusions: Preventive approaches such as limiting file reuse and constructing a glide path can reduce the occurrence of file separation. Operators should be familiar with the number of uses of the instrument before fatigue and should be trained through workshops and refresher courses. Keywords: Dentists. Endodontists. Pakistan. Prevalence. https://orcid.org/0000-0001-5865-4507 https://orcid.org/0009-0003-3016-5762 https://orcid.org/0000-0002-4495-5197 https://orcid.org/0009-0002-3499-2215 https://orcid.org/0000-0002-7644-448X https://orcid.org/0009-0007-3021-9635 2 Hassan et al. Braz J Oral Sci. 2023;22:e233938 Introduction Eight out of ten dentists have experienced endodontic file fracture at some point in their clinical career, especially in the posterior dentition1,2. File separation is an unfortu- nate, challenging event that may impede an endodontic treatment and lead to failure, depending on the stage, type, and location of file breakage. Various risk factors that can cause instrument separation include severely curved canals, older-fatigued files, inexperience, wrong motion, manufacturing flaws, excessive force, and not following the manufacturer’s guidelines3-5. A mishap like an instrument separation can be managed conservatively or surgically based on the severity of the case, patients’ compliance, and operators’ proficiency. The Conservative approach involves bypassing the fragment, removing the frag- ment, or sometimes keeping the fragment along with the obturation in case there is no residual infection6,7. The fate of the teeth with a broken instrument depends on bacterial load, the stage at which the instrument got separated, periapical lesion, and final obturation8. Many techniques and systems have been developed for the removal of separated instruments. The most efficient and reliable are ultrasonic instruments and dental optical microscopes5,9. Other Instrument Retrieval systems (IRS), also known as tube- like systems, are technique-sensitive, require excessive dentin removal to expose the coronal part of the fragment, and pose a risk of perforation6,10. These systems include the Endo-Extractor system, Masserann kit, Cancelier instrument, and Mounce extractor11,12. While modern endodontic files are designed to be strong and durable, file separation can still happen. The implementation of strategies to prevent instru- ment separation, the efficient handling of incidents when they occur, and familiarity with different retrieval methods not only decrease the occurrence of separation but also save time and improve treatment outcomes4,10. This study aimed to find the incidence and awareness of endodontic instrument sepa- ration and its management among dental house officers, postgraduate trainees, dem- onstrators, and consultants working in dental institutes in Punjab. Understanding the incidence and management of instrument fracture in endodontics is crucial for both dental practitioners and patients as it will improve the quality of endodontic treatment, reduce the risk of complications, and reduce the financial burden and inconvenience associated with additional treatments. Methods This descriptive cross-sectional study was conducted from December 20th, 2021, to  December 13th, 2022, after the approval of the Institutional Review Board (IRB) of the Institute of Dentistry, CMH Lahore Medical College (649/ERC/CMH/LMC), and with the permission of the participating institutes. Informed consent was obtained, and the confidentiality statement was stated in the questionnaire. Questionnaires were distributed online among dentists, including demonstrators, postgraduate train- ees, house officers, and consultants working in the operative departments of five pri- vate and two public dental institutes in Punjab, through purposive sampling using 3 Hassan et al. Braz J Oral Sci. 2023;22:e233938 email and WhatsApp. Dental graduates who were not part of the operative clinics, undergraduates in the dental clinics, and those who did not give consent were not included in the study. The questionnaire was developed by the authors and consisted of 24 closed-ended questions. The first part targeted demographics such as age, gender, institute, desig- nation, and years of experience. The second part of the questionnaire dealt with the incidence of endodontic file separation as well as the awareness and attitude of den- tists towards it and their understanding of management options. The questionnaire underwent several revisions before the draft was finalized, which underwent face and content validity through expert review. The data were analyzed using the IBM Statistical Package for Social Sciences (SPSS version 24, IBM Corporation). Descriptive statistics were employed to tabulate the per- centages and frequencies of the variables. The Chi-Square Test was used to compare the categorical variables. A p-value less than or equal to 0.05 was taken as significant. Results In the present study, 160 individuals were approached, and 149 respondents responded to the questionnaire; the response rate was 93.1%. The demographics have been expressed in Table 1. Table 1. Demographical information of the participants Demographics n % Gender Male 59 39.6 Female 90 60.4 Institute Private 83 55.7 Public 66 44.3 Designation House Officer 46 30.9 Post Graduate Trainee 47 31.5 Demonstrator 27 18.1 Consultant 29 19.4 Years of Experience Less than 2 years 55 36.9 2 to 5 years 56 37.6 More than 5 years 38 25.5 The frequency of endodontic instrument separation was 69.1% (n=103), the attempt of retrieval/bypass was 44.9% (n=67), and the occurrence of a secondary error during the retrieval/bypass was 47.6% (n=71). The frequency of file separation, retrieval attempt, and secondary error during retrieval or bypass among different designations have been illustrated in Figure 1. There was a significant difference between the house officers, postgraduate trainees, demonstra- 4 Hassan et al. Braz J Oral Sci. 2023;22:e233938 tors, and consultants pertaining to the file separation (X2=50.7, p=<0.001*), retrieval attempt/bypass (X2=26.3, p<0.001*) and the occurrence of secondary file separation during retrieval/bypass (X2=35.1, p<0.001*). Postgraduate trainees experienced the most instrument separations (n=45, 43.6%), made the most retrieval attempts (n=33, 49.2%), and experienced the most secondary errors during retrieval (n=37, 52.1%), followed by consultants, demonstrators, and house officers (Figure 1). File Separation Retrieval Attempt House Officers Post-graduate Trainees Demonstrators Consultants Secondary Error 13.5 11.9 11.2 43.6 49.2 52.1 4.914.91 16.9 23.3 19.4 19.7 0 10 20 30 40 50 60 % Figure 1. Frequency of endodontic file separation experience, retrieval attempt, and secondary error during retrieval or bypass Most respondents showed a positive perception when it came to informing patients and departments about the file separation (Table 2). Table 2. Informing patients and department about the endodontic file separation incident Always n(%) Sometimes n(%) Rarely n(%) Never n(%) Informing the patient 59 (39.6) 45 (30.2) 14 (9.4) 31 (20.8) Informing the department 62 (41.6) 55 (36.9) 16 (10.7) 16 (10.7) The comparison between private and public dental institutes regarding frequency of endodontic file separation, type of file separated, length of file, and cause of separa- tion have been expressed in Table 3. Manual endodontic files were more frequently broken in public dental institutes (p=0.003). However, there was no difference reported regarding the occurrence of instrument separation (p=0.519), manufacturing type (p=0.29), file length (p=0.322), and cause of separation (p=0.496) (Table 3). 5 Hassan et al. Braz J Oral Sci. 2023;22:e233938 Table 3. Comparison between private and public dental institutes regarding frequency of endodontic file separation, file type, length, and causes of separation Variables n(%) Private (n)% Public (n)% X2 p Occurrence of File Separation Yes 103 (69.1) 57 (68.6) 46 (69.7) 0.018 0.519 No 46 (30.9) 26 (31.3) 20 (30.3) File Type Manual 104 (69.8) 50 (60.2) 54 (81.8) 8.12 0.003 Rotary 45 (30.2) 33 (39.7) 12 (18.1) Manufacturing Type Stainless Steel 113 (75.8) 61 (73.4) 52 (78.7) 0.562 0.290 Nickle Titanium 36 (24.2) 22 (26.5) 14 (21.2) File Length Short 90 (60.4) 52 (62.6) 38 (57.5) 0.396 0.322 Long 59 (39.6) 31 (37.3) 28 (42.4) Cause of File Separation Older fatigued files 86 (57.7) 50 (60.2) 36 (54.5) 3.38 0.496 Improper motion 29 (19.5) 13 (15.6) 16 (24.2) Complex canal anatomy 19 (12.8) 13 (15.6) 6 (9) Calcified canals 9 (6.0) 4 (4.8) 5 (7.5) Inexperience 6 (4.0) 3 (3.6) 3 (4.5) The frequencies of instrument separation at different stages of root canal treatment, susceptible teeth, susceptible canal, and the part of root canal have been tabulated in Table 4. Table 4. Frequency of endodontic instrument separation at different stages, parts of the canal, as well as susceptible teeth and canal Variables n % Stage of Root Canal Cleaning and shaping 108 72.5 During Negotiating 41 27.5 Part of Canal Apical 97 65.1 Middle 50 33.6 Coronal 2 1.3 Susceptible Teeth Molar 132 88.6 Premolar 7 4.7 Canine 6 4.0 Incisor 4 2.6 Continue 6 Hassan et al. Braz J Oral Sci. 2023;22:e233938 Continuation Susceptible Canal Mesiolingual 84 56.4 Mesiobuccal 81 54.4 Distolingual 11 7.4 Distal 9 6 Palatal 9 6 Distobuccal 8 5.4 The management of instrument separation in the case of the symptomatic and non-symptomatic teeth is shown in Table 5. The management of separated endodon- tic files, their retrieval technique used, and the presence of an instrument retrieval system in the departments are expressed in Table 6. Table 5. Management in case of instrument fracture in a symptomatic and non-symptomatic tooth Variables Non-Symptomatic Tooth n(%) Symptomatic Tooth n(%) Complete treatment with fragment inside 65 (43.6) 21 (14.1) Bypass of fragment 58 (38.9) 71 (47.7) Removal of fragment 6 (4.0) 13 (8.7) Refer to endodontist 16 (10.7) 29 (19.5) Refer to the surgery department 4 (2.7) 15 (10.1) Table 6. Management of endodontic file separation, retrieval technique used, and instrument retrieval system present in the department Variables n % Management of file separation Bypass Attempt 106 71.1 Retrieval Attempt 67 45 Retrieval Technique Used Ultrasonics 46 30.9 IRS (Instrument Retrieval Kit) 6 4.0 Wire-loop technique 19 12.8 Instrument Retrieval System in Department No System 113 75.8 Ultrasonics 14 9.4 IRS (Instrument Retrieval Kit) 14 9.4 Wire-loop technique 8 5.4 Discussion Modern endodontics witnesses a plenitude of progress resulting from continuous scientific innovations and development in technologies, techniques, and resources. 7 Hassan et al. Braz J Oral Sci. 2023;22:e233938 The present study entails identifying all the contributing factors and highlighting the necessity of developing proper parameters to avert the occurrence of such challenging situations12,13. The results of the present study reported the highest incidence of file separation amongst postgraduate trainees (43.6%), which is in agreement with the previous liter- ature13,14. The higher incidence of file separation among postgraduates and endodon- tists can be explained by the higher number of endodontic cases as well as complex cases performed per week. On the contrary, Pedir et al.15 (2016) found that general dentists had the highest prevalence of instrument separation compared to dental stu- dents working in clinics. Dental students and house officers may have a lower inci- dence of instrument separation and adverse outcomes, as they are usually assigned simpler, less complicated cases. It can be very challenging to ascertain the incidence of file fractures as a substantial number of clinical cases get overlooked due to flawed reporting. The fundamental legal and ethical dental code urges the operator to notify the patient and the depart- ment about instrument separation and prognosis. In the present study, most of the participants informed patients as well as their departments. The results were in accor- dance with previous studies16-18. A significant proportion of the file separation cases in the present study were from private dental hospitals, with manual stainless files of shorter lengths being more frequently separated. These results were consistent with the study conducted by Pedir et al.15 (2016). However, these results were against the authors’ expectations, as private dental institutes in Pakistan are better developed, well-funded, and tech- nologically advanced. The operators in public dental institutes may experience a much higher flow of patients and hence have more experience, leading to fewer events of instrument fracture1. Recent literature suggests a higher incidence of rotary NiTi instrument separation as they are frequently subjected to a combination of torsional and cyclic stresses, especially at higher speeds19. The conflicting results between the present study and the literature can be explained by the recent shift to the newer NiTi file system and its more frequent use20. The fracture of stainless-steel files is generally attributed to overuse, as reported by the majority (57.7%) of the participants of the present study. Since 2007, The Department of Health in the United Kingdom has mandated that all endodontic files are for single-use. However, no such regulation exists within other European jurisdictions, and the number of times an instrument is used varies with the operator. Presently, providing a definitive guideline to propose a safe number of uses is challenging, but it is accepted that files should be discarded after signs of distortion21. Most of the literature identifies that most instruments fractured in the apical third of the canal due to its maximum curvature and smallest diameter2,3,6. Similar results were found in the present investigation. The higher incidence of fracture during clean- ing and shaping can be attributed to the failure to obtain straight-line access and ineffective endodontic irrigation. 8 Hassan et al. Braz J Oral Sci. 2023;22:e233938 Separation of instruments in the later stages of instrumentation of an aseptic canal has shown a better prognosis. The literature suggests instrumentation and obturation of the canal coronal to the retained instrument with regular follow-up. A similar trend was reported in the present study. However, a bypass or retrieval attempt is advo- cated in symptomatic cases or cases with periapical lesions, as practiced by 47.7% of the participants of the present study6,10. Most respondents chose to bypass retrieval as their treatment option because it is believed to be the safest and the least invasive treatment path. In contrast, retrieval is a rather challenging procedure, as mentioned in the previous literature. Moreover, ultrasonics with a dental operating microscope is considered the most successful method for instrument removal among various devices and techniques described in the literature9,10,14,15. Most of the participants in the present study would also use ultra- sonics to retrieve the broken fragment. Around three-fourths (75.8%) of the respondents reported an absence of the instru- ment retrieval system in their department. Although no certified instructions have been published concerning the treatment of instrument separation, it is recommended to initially aim at bypassing the separated fragment because this has been proved to be a more conservative approach. However, where bypassing is hopeless, retrieval of the fragment is advised. A retained separated instrument in a symptomatic tooth can compromise the prognosis of the tooth and even necessitate further interventions such as surgical endodontics or tooth extraction, as stated by Gandevivala et al.22 (2014), and Maqbool et al.23 (2023). In conclusion, Endodontic file separation remains a challenging issue in dental hospi- tals. Postgraduate trainees and consultants reported a higher incidence of file separa- tion, especially in manual, stainless steel, and shorter files, and preferred keeping the separated instrument inside, unless the tooth was symptomatic. The operators must be trained through seminars and refresher courses. Preventive measures, such as limiting file reuse and raising awareness of the number of times an instrument can be used before fatigue sets in, can reduce the occurrence of separation and can signifi- cantly influence the overall patient experience and clinical outcomes. Conflict of Interest The authors declare no conflicts of interest. Funding Statement The authors received no funding. Acknowledgments None. Data Availability Datasets related to this article will be available to the corresponding author upon request. 9 Hassan et al. Braz J Oral Sci. 2023;22:e233938 Author Contribution All authors have actively participated, at least, in two distinct criteria about the author- ship and. have revised and approved the final version of the manuscript. Specific con- tributions made by each author are given below: Dr. Hammad Hassan: Conception and design, drafting of the article, interpretation of data, statistical analysis. Dr. Syed Moiz Ali: Conception and design, collection of data, drafting of article. Dr. Baneen Khawar: Drafting of manuscript, critical revision, data interpretation. Dr. Sidra Riaz: Data collection, drafting of manuscript, data interpretation. Dr. Razia Zia: Data interpretation, data collection, proof reading. Dr. Marij Hameed: Critical revision, data collection. References 1. 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