Advertisement

Compliance with Key Practices of Root Canal Treatment Varies by the Reward System Applied in Public Dental Services

Open AccessPublished:August 02, 2021DOI:https://doi.org/10.1016/j.joen.2021.07.018

      Abstract

      Introduction

      To assess clinical practices in root canal treatments (RCTs) performed by general dental practitioners under 2 different reward schemes applied in public dental services.

      Methods

      This study used a retrospective design with tooth as the observation unit. The data included all teeth (n = 547) with nonsurgical primary RCT completed in 2016. Electronic documents included treatment details and radiographs. RCT assessment covered 4 key items: taking pre- and postoperative radiographs, using a rubber dam, measuring working length. Assessed dichotomies indicated whether practices were adequate. Dentists’ reward schemes were “salaried” and “fee-for-service.” Chi squared tests analyzed frequency differences.

      Results

      RCTs formed 2 groups by the reward scheme: 305 RCTs were performed by salaried dentists and 242 by fee-for-service dentists. Preoperative radiographs were diagnosable for 76.1% and postoperative radiographs, for 95.1% of all RCTs. Rubber dam use was documented for 28.9% of the RCTs, more frequently when performed by salaried than by fee-for-service dentists (43.9% vs 9.9%, P < .001). Working length measurement was documented for 72.9% of the RCTs, more frequently for RCTs performed by salaried than by fee-for-service dentists (85.2% vs 57.4%, P < .001). All 4 key items were assessed as adequate in 19.0% of all RCTs, more frequently when performed by salaried than by fee-for-service dentists (29.5% vs 5.8%, P < .001).

      Conclusions

      Deficiencies in RCTs, particularly underuse of rubber dams call for further research to understand the reasons for noncompliance with good clinical practice guidelines.

      Key Words

      This paper sheds light on RCT practices in everyday clinical work. Assessment of practices in public dental services revealed variation in treatments performed, indicating differences in compliance with guidelines for good clinical practice both by type of tooth and by type of reward scheme applied for dentists.
      Endodontic associations in Europe and in the United States have given guidelines for maintaining and updating practices for root canal treatment (RCT). The main keystones of instructions for good clinical RCT practices comprise a preoperative radiograph, isolation of the tooth by a rubber dam, determination of working length, and a postoperative radiograph of the root filling
      European Society of Endodontology
      Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
      ,
      American Association of Endodontists
      Guide to Clinical Endodontics, Sixth Edition.
      .
      Research analyzing implementation of clinical practices, the major topic being use of rubber dams, has applied questionnaire-based data revealing varying RCT practices
      • Whitworth J.M.
      • Seccombe G.V.
      • Shoker K.
      • et al.
      Use of rubber dam and irrigant selection in UK general dental practice.
      ,
      • Eleazer P.D.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      Techniques and materials used by general dentists during endodontic treatment procedures. Findings from the National Dental Practice-Based Research Network.
      . Regrettably, serious underuse of rubber dams appears to be true worldwide, as shown in reviews
      • Ahmad I.A.
      Rubber dam usage for endodontic treatment: a review.
      ,
      • Ahmed H.M.A.
      • Cohen S.
      • Lévy G.
      • et al.
      Rubber dam application in endodontic practice: an update on critical educational and ethical dilemmas.
      and in a recently published opinion that the rubber dam is not used enough
      • Marshall K.
      ‘Dam it-it’s easy!’-or is it?.
      . A questionnaire-based study from the United Kingdom reports that as few as 9% to 33% of dentists use rubber dams always or frequently and 44% to 66% never
      • Whitworth J.M.
      • Seccombe G.V.
      • Shoker K.
      • et al.
      Use of rubber dam and irrigant selection in UK general dental practice.
      . In another study, 19% of dentists claimed to use rubber dams routinely and 44.5% never
      • Jenkins S.M.
      • Hayes S.J.
      • Dummer P.M.H.
      A study of endodontic treatment carried out in dental practice within the UK.
      . In Ireland, 27% to 40% of general dental practitioners (GDPs) reported using rubber dam always, and 26% to 39% never
      • Lynch C.D.
      • McConnell R.J.
      Attitudes and use of rubber dam by Irish general dental practitioners.
      . In the United States, 44% to 47% of dentists described using rubber dams consistently, and 15% reported never using them
      • Eleazer P.D.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      Techniques and materials used by general dentists during endodontic treatment procedures. Findings from the National Dental Practice-Based Research Network.
      ,
      • Anabtawi M.F.
      • Gilbert G.H.
      • Bauer M.R.
      • et al.
      Rubber dam use during root canal treatment: findings from the Dental Practice-Based Research Network.
      ,
      • Lawson N.C.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      General dentists’ use of isolation techniques during root canal treatment: from the National Dental Practice-based Research Network.
      . A Danish study showed a notable improvement in practices as the proportion of dentists reporting often applying rubber dams increased from 4% in 2003 to 29% in 2013
      • Markvart M.
      • Fransson H.
      • Bjørndal L.
      Ten-year follow-up on adoption of endodontic technology and clinical guidelines amongst Danish general dental practitioners.
      . A recent study from Lithuania noted that 12% of GDPs used rubber dams always or often, and 66% never used them
      • Peciuliene V.
      • Rimkuviene J.
      • Aleksejuniene J.
      • et al.
      Technical aspects of endodontic treatment procedures among Lithuanian general dental practitioners.
      . In contrast to other countries, in Sweden and Norway, 96.9% of GDPs reported routinely using rubber dams
      • Malmberg L.
      • Hägg E.
      • Björkner A.E.
      Endodontic infection control routines among general dental practitioners in Sweden and Norway: a questionnaire survey.
      .
      The rest of the keystones and core issues of good RCT practice have been less studied. In the United Kingdom, 89% of dentists reported using a radiograph to determine working length, whereas more than 75% reported routinely taking a postoperative radiograph to check the root filling
      • Jenkins S.M.
      • Hayes S.J.
      • Dummer P.M.H.
      A study of endodontic treatment carried out in dental practice within the UK.
      . In Denmark, 15% of dentists in 2003 and 54% in 2013 reported the use of an apex locator
      • Markvart M.
      • Fransson H.
      • Bjørndal L.
      Ten-year follow-up on adoption of endodontic technology and clinical guidelines amongst Danish general dental practitioners.
      .
      Implementation of RCT has rarely been studied using patient documents. In Finland, a previous study of public dental services provided to young adults, analyzed the process of RCT in 1994 by scrutinizing documents of 144 completed RCTs
      • Helminen S.E.
      • Vehkalahti M.
      • Kerosuo E.
      • et al.
      Quality evaluation of process of root canal treatments performed on young adults in Finnish public oral health service.
      . The report revealed a paucity in practices; in 34% of RCT cases a preoperative radiograph and in 52% a postoperative radiograph was taken, and for 62% of RCTs, the measurement of working length was verified. The findings “indicated a discrepancy between consensus guidelines and everyday practice.”
      • Helminen S.E.
      • Vehkalahti M.
      • Kerosuo E.
      • et al.
      Quality evaluation of process of root canal treatments performed on young adults in Finnish public oral health service.
      This study assessed clinical practice in RCTs performed by GDPs under 2 different reward schemes in public dental services. We hypothesized that the implementation of RCTs complies with selected keystones designed in guidelines of good clinical practice and is similar regardless of the reward scheme.

      Materials and Methods

       Ethical Consideration

      The City of Porvoo, Department of Social Services and Healthcare, Finland, approved the study protocol (Dno. 1472/33-18). Data are based on electronic patient documents including radiographs. The document-based information is stored in a database using running numbers for identification of the patients to ensure confidentiality.

       Setting

      All inhabitants in Finland are entitled to public health care services in their community of residence. Dental services are free of charge for those younger than 18 years and highly subsidized for all adults. In public health care services, all dentists who are hired, receive a fixed monthly salary plus incentives paid by the numbers of coded items of treatments given. Patients’ flow to public services has considerably increased in the 2000s
      • Suominen A.L.
      • Helminen S.
      • Lahti S.
      • et al.
      Use of oral health care services in Finnish adults - results from the cross-sectional Health 2000 and 2011 Surveys.
      , forcing many public sector units to seek added services from private providers by offering vouchers to patients. To purchase additional services from the private sector, the public sector units run an official proposal with fixed fees by service item. The public dentist initiates the use of voucher-based service by referring the patient to private dentists via their companies that are admitted to the bilateral agreement with the public sector unit. The private dentists will receive a fee-for-item reward for services they provide. For patients, the fees are the same regardless of the treatment sector. The patient documentation of voucher-paid treatments is included in the electronic database, maintained by the public sector management.

       Study Design and Data Collection

      The study was carried out using a retrospective design, with the observation unit being a tooth. The data included teeth receiving nonsurgical primary RCT performed by GDPs in public dental services (PDS) in the city of Porvoo, Finland. No sampling was done, and the data included all nonsurgical primary RCTs completed in 2016. The patient documents were in electronic form, including written and coded recordings and radiographs. The documentation of treatment is obligatory, and the operators are required to record all measures legally by detail to verify the treatment given.
      For our data, the documents were scrutinized by one of the authors (SL), a staff member of the Porvoo PDS. A total of 547 completed nonsurgical primary RCTs met the inclusion criteria and were analyzed here. RCT teeth were identified using the ISO 3950 system, and later categorized as anteriors (incisors and canines), premolars, and molars.
      Four key items, obligatory for good clinical practice, were chosen from the guidelines given by the European Society of Endodontology and the American Association of Endodontists
      European Society of Endodontology
      Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
      ,
      American Association of Endodontists
      Guide to Clinical Endodontics, Sixth Edition.
      : preoperative radiograph showing the full root(s) and 2 to 3 mm of the periapical region, isolation of the tooth using a rubber dam to prevent transfer between the RCT and oral cavity, determination of working length using an electronic and/or radiographic device to record the preparation length of root canals, and postoperative radiograph, showing 2 to 3 mm of the periapical region to check the quality of the root filling. Each item was assessed to determine whether it was implemented adequately. The dichotomies used for radiographs were “diagnosable” and “inaccessible,” and for determination of working length “documented” and “not documented.” The isolation method of the tooth was initially recorded in 3 categories: “rubber dam,” “matrix band,” and “not documented,” first used in the descriptive analyses, and further analyzed using the dichotomy of “using” or “not using” a rubber dam. For each RCT tooth, the number of positive dichotomies described the adequacy of the RCT.
      Further background for completed RCTs was gathered regarding the dentist’s reward scheme. Those dentists hired by the PDS in Porvoo belonged to the “salaried” scheme, whereas the other group included private dentists who had a bilateral contract and were rewarded according to the “fee-for-service” scheme. No further information on the dentists could be collected due to strict privacy rules. The patient’s personal information included sex and age at the first RCT visit.

       Statistical Methods

      Descriptive statistics included frequency distributions, means, and standard deviations (SDs). Differences in frequencies of the subgroups were analyzed using χ2 tests, whereas differences in mean values were assessed using 1-way analysis of variance. Analyses and graphics were performed with Survo MM software version 3.4.1 (Survo Systems, Helsinki, Finland).

      Results

      The nonsurgical primary RCTs (n = 547) formed 2 groups according to the reward scheme: 305 RCTs (55.8%) were performed by salaried dentists and 242 RCTs (44.2%) RCTs by dentists with a fee-for-service reward (Table 1). Molars dominated in both groups and were less frequent in RCTs performed by salaried dentists than by fee-for-service dentists (46.2% vs 71.9%, P < .001). Patients’ age ranged from 9.1 to 85.4 years, the mean being 43.5 (SD 16.8) years, and slightly more than half of patients were women. No difference was found in patients’ age by operator’s reward scheme.
      Table 1Characteristics of Nonsurgical Primary Root Canal Treatments (RCTs) Performed in Public Dental Services and According to the Dentist's Reward Scheme
      Characteristics of RCT teethRCT teethRCT teeth by dentist’s reward schemeP Value
      All, n (%)Salaried, n (%)Fee-for-service, n (%)
      Total547 (100.0)305 (55.8)242 (44.2)
      Type of tooth<.001
       Anterior89 (16.3)68 (22.3)21 (8.7)
       Premolar143 (26.1)96 (31.5)47 (19.4)
       Molar315 (57.6)141 (46.2)174 (71.9)
      Patient’s sex.825
       Women300 (54.8)166 (54.4)134 (55.4)
       Men247 (45.2)139 (45.6)108 (44.6)
      Patient’s age (y).885
       Mean (SD)43.5 (16.8)43.4 (18.1)43.6 (15.0)
       Median; Range43.8; 9.1–85.443.4; 9.1–85.444.3; 16.7–77.4
      Status of radiographs taken during RCT is shown in Table 2. Diagnosable preoperative radiographs were available for 76.1% of the RCTs, less frequently in treatments performed by salaried dentists than by fee-for-service dentists (72.1% vs 81.0%, P = .016). Diagnosable postoperative radiographs were available for 95.1% of all RCTs, with no difference by dentist’s reward scheme. Of all radiographs, 2% to 3% were undiagnosable, as they did not cover the apical area. For the rest of the RCTs, pre- and postoperative radiographs were absent and thus inaccessible. No difference was found in the frequency by type of tooth (not shown in Table 2).
      Table 2Obligatory Radiographs During Nonsurgical Primary Root Canal Treatments (RCTs) Performed in Public Dental Services and According to the Dentist’s Reward Scheme
      Type and adequacy of radiographsAll RCT teethRCT teeth by dentist’s reward schemeP value
      n (%)Salaried, n (%)Fee-for-service, n (%)
      n = 547n = 305n = 242
      Preoperative.016
       Diagnosable416 (76.1)220 (72.1)196 (81.0)
       Inaccessible131 (23.9)85 (27.9)46 (19.0)
      Postoperative.707
       Diagnosable520 (95.1)289 (94.8)231 (95.5)
       Inaccessible27 (4.9)16 (5.2)11 (4.5)
      Table 3 shows the frequencies of isolation methods used. The use of rubber dams was documented for 28.9% and use of matrix band, for 12.2% of the RCTs, whereas for 58.9% of RCTs no documentation existed. Teeth were isolated using rubber dams more frequently when RCTs were performed by salaried dentists than by fee-for-service dentists (43.9% vs 9.9%, P < .001), and this difference was significant for each type of tooth. Use of rubber dam was most frequent for anterior and least frequent for molar RCTs (39.3% vs 23.2%, P = .005), the corresponding figures for RCTs performed by fee-for-service dentists being 19.0% and 10.3% (P = .062). Use of matrix band as the isolation was more frequent for RCTs performed by fee-for-service dentists than by salaried dentists (21.5% vs 4.9%, P < .001).
      Table 3Isolation Methods During Nonsurgical Primary Root Canal Treatments (RCTs) Performed in Public Dental Services and According to the Dentist’s Reward Scheme and the Type of Tooth
      Isolation method by type of toothAll RCT teethRCT teeth by dentist’s reward schemeP Value
      n (%)Salaried, n (%)Fee-for-service, n (%)
      All RCT teethn = 547n = 305n = 242<.001
       Rubber dam158 (28.9)134 (43.9)24 (9.9)
       Matrix band67 (12.2)15 (4.9)52 (21.5)
       Not documented322 (58.9)156 (51.1)166 (68.6)
      Anteriorsn = 89n = 68n = 21.021
       Rubber dam35 (39.3)31 (45.6)4 (19.0)
       Matrix band5 (5.6)5 (7.4)0 (0.0)
       Not documented49 (55.1)32 (47.0)17 (81.0)
      Premolarsn = 143n = 96n = 47<.001
       Rubber dam50 (35.0)48 (50.0)2 (4.3)
       Matrix band17 (11.9)5 (5.2)12 (25.5)
       Not documented76 (53.1)43 (44.8)33 (70.2)
      Molarsn = 315n = 141n = 174<.001
       Rubber dam73 (23.2)55 (39.0)18 (10.3)
       Matrix band45 (14.3)5 (3.5)40 (23.0)
       Not documented197 (62.5)81 (57.4)116 (66.7)
      P value by type of tooth.005.280.062
      Working length measurement was documented for 72.9% of the RCTs (Table 4). Measurements were more frequent for RCTs performed by salaried dentists than by fee-for-service dentists (85.2% vs 57.4%, P < .001) and in anteriors than in molars (79.8% vs 68.9%, P = .043).
      Table 4Working Length Measurement During Nonsurgical Primary Root Canal Treatments (RCTs) Performed in Public Dental Services and According to the Dentist’s Reward Scheme
      Working length measurementAll RCT teethRCT teeth by dentist’s reward schemeP value
      n (%)Salaried, n (%)Fee-for-service, n (%)
      All RCT teethn = 547n = 305n = 242<.001
       Documented399 (72.9)260 (85.2)139 (57.4)
       Not documented148 (27.1)45 (14.8)103 (42.6)
      Anteriorsn = 89n = 68n = 21.087
       Documented71 (79.8)57 (83.8)14 (66.7)
       Not documented18 (20.2)11 (16.2)7 (33.3)
      Premolarsn = 143n = 96n = 47<.001
       Documented111 (77.6)84 (87.5)27 (57.4)
       Not documented32 (22.4)12 (12.5)20 (42.6)
      Molarsn = 315n = 141n = 174<.001
       Documented217 (68.9)119 (84.4)98 (56.3)
       Not documented98 (31.1)22 (15.6)76 (43.7)
      P value by type of tooth.043.749.664
      Adequate implementation of all 4 key items obligatory for good RCT practice was found in 104 RCTs (19.0%). A total of 235 (43.0%) RCTs had 3, 166 (30.3%) had 2, and 40 (7.3%) had 1 key item completed. All 4 key items were absent in 2 (0.4%) RCTs, in 1 canine and 1 premolar, both in the mandible. Figure 1 shows distributions (%) of performed RTCs according to the number of adequately accomplished key items per RCT, separately by the reward system. Accomplishment of the key items was more frequent for RCTs performed by salaried dentists than by fee-for-service dentists (P < .001). This difference was prominent for RCTs with full completion of the key items: 29.5% vs 5.8%.
      Figure thumbnail gr1
      Figure 1Distributions (%) of performed nonsurgical primary root canal treatments (RCTs) by the number of adequately completed items per RCT, separately according to the dentist’s reward scheme (salaried and fee-for-service). For each RCT, 4 key items were assessed.

      Discussion

      The focus of this study was on nonsurgical primary RCTs performed by GDPs in everyday practice in PDS. The main findings were deficiencies in compliance with the guidelines of good clinical practice and differences in the execution of RCTs according to the reward scheme. Consequently, these findings gave no support to our hypotheses.
      The 4 key items that we selected to analyze are obligatory to maintaining good clinical practice
      European Society of Endodontology
      Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
      ,
      American Association of Endodontists
      Guide to Clinical Endodontics, Sixth Edition.
      . Our selection was targeted to the following prerequisites: pre- and postoperative radiographs that are needed for proper starting of RCTs and valid judgment of root fillings made; use of rubber dams that is obligatory for patient safety and avoidance of harmful contamination from oral microbes; and determination of working length that is essential for ensuring optimal boundaries in shaping of root canals. Compliance with taking postoperative radiographs was almost complete, as 95.1% of the RCTs had documented findings. For the rest of the 4 key items, shortcomings were revealed. Compliance was somewhat insufficient with preoperative radiographs (76.1% of RCTs) and with measurements of working length (72.9% of RCTs). The most regrettable deficiency was found in use of rubber dams, documented in only 28.9% of all RTCs. In addition, the absence of the detailed recording of the RCTs was at its greatest regarding the use of rubber dams. Despite the different method of data collection indicating incomparability, our findings are broadly in line with most of the questionnaire-based studies
      • Whitworth J.M.
      • Seccombe G.V.
      • Shoker K.
      • et al.
      Use of rubber dam and irrigant selection in UK general dental practice.
      • Eleazer P.D.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      Techniques and materials used by general dentists during endodontic treatment procedures. Findings from the National Dental Practice-Based Research Network.
      • Ahmad I.A.
      Rubber dam usage for endodontic treatment: a review.
      ,
      • Jenkins S.M.
      • Hayes S.J.
      • Dummer P.M.H.
      A study of endodontic treatment carried out in dental practice within the UK.
      ,
      • Lynch C.D.
      • McConnell R.J.
      Attitudes and use of rubber dam by Irish general dental practitioners.
      ,
      • Lawson N.C.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      General dentists’ use of isolation techniques during root canal treatment: from the National Dental Practice-based Research Network.
      ,
      • Markvart M.
      • Fransson H.
      • Bjørndal L.
      Ten-year follow-up on adoption of endodontic technology and clinical guidelines amongst Danish general dental practitioners.
      . A closer pertinent finding proved that use of rubber dams in RCTs performed by fee-for-service dentists was as infrequent as in a large questionnaire-based study among GDPs in Lithuania
      • Peciuliene V.
      • Rimkuviene J.
      • Aleksejuniene J.
      • et al.
      Technical aspects of endodontic treatment procedures among Lithuanian general dental practitioners.
      .
      The data from the Porvoo PDS cover all nonsurgical primary RCT teeth that had root canals filled in during 2016, thus being a strength of this study. Accordingly, the presented proportions are not sample-based estimates, but parameters for the entire PDS. Although generalization of the present findings to nationwide PDS warrants caution, the findings provide a useful starting point for comparisons. To our knowledge, just one earlier study
      • Helminen S.E.
      • Vehkalahti M.
      • Kerosuo E.
      • et al.
      Quality evaluation of process of root canal treatments performed on young adults in Finnish public oral health service.
      has reported findings based on patient documentation, collected equivalently to our data, albeit without reward data because at that time all operators were salaried. A limitation of our study is that, apart from the current reward system applied, other characteristics of operators were inaccessible.
      Evaluation of the selected 4 keystone RCT items was based on recordings made on patient documents during the treatment. This is an additional strength of the data analyzed here, because the recordings form a legal document and thus verify the details of the treatment given. The RCT execution could be confirmed from the patient document recordings and the 4 keystones objectively evaluated as being either adequate or inadequate. Unfortunately, the details of RCT were in part insufficiently recorded, thus proving negligence to abide by the instructions for good clinical practice. Despite incomplete patient documentation, our data enlarged the knowledge of the reality of the implementation of RCT and opened a new path to assess details of RCT practices, whereas most of the earlier studies were based only on questionnaires addressed to dentists to mainly inquire about their opinions, attitudes, and practices in rubber dam use.
      Molar teeth dominated RCT in both sectors and were clearly more frequent in those performed by fee-for-service dentists than by salaried dentists. This indicates that salaried dentists were keen to offer a voucher to patients diagnosed with need of RCT in a molar tooth. Referring of molar RCTs to fee-for-service dentists may indicate challenges faced by salaried dentists who may consider the tightly scheduled clinical hours insufficient to perform time-consuming molar RCTs. Reasons for referring patients to fee-for-service dentists are unknown but may be due to continuous pressure to achieve the most cost-effective outcome when having sense of the lack of time available, and of demands and difficulties with molar RCTs, and fear of ending up with mistakes or failure
      • Dahlström L.
      • Lindwall O.
      • Rystedt H.
      • et al.
      ‘Working in the dark’: Swedish general dental practitioners on the complexity of root canal treatment.
      .
      Generally, implementation of RCT is tightly defined and supervised until a dentist’s graduation
      • De Moor R.
      • Hülsmann M.
      • Kirkevang L.L.
      • et al.
      Undergraduate curriculum guidelines for endodontology.
      ,
      • Laukkanen E.
      • Vehkalahti M.M.
      • Kotiranta A.K.
      Impact of type of tooth on outcome of non-surgical root canal treatment.
      . Afterward, during the clinical years, no compulsory auditing of practices is carried out, but guidelines given by endodontic associations are available to keep one’s expertise voluntarily updated. A recent review analyzed this dilemma and stated that “there is a clear discrepancy in what GDPs are taught in dental school and what they practice after graduation.”
      • Ahmed H.M.A.
      • Cohen S.
      • Lévy G.
      • et al.
      Rubber dam application in endodontic practice: an update on critical educational and ethical dilemmas.
      Further, a report from the United Kingdom discussing risk management in clinical endodontic practice, stated that “the standards of treatment have been shown to have fallen short of acceptable guidelines.”
      • Webber J.
      Risk management in clinical practice. Part 4.
      The reluctance to adhere to adequate RCT practices has been widely reported and discussed
      • Gilbert G.H.
      • Riley J.L.
      • Eleazer P.D.
      • et al.
      Discordance between presumed standard of care and actual clinical practice: The example of rubber dam use during root canal treatment in the national dental practice-Based research network.
      . Among others, the American Association of Endodontists has given an explicit position statement on dental dams stating that “Only dental dam isolation minimizes the risk of contamination of the root canal system by indigenous oral bacteria”. Despite this definitive statement and strict instructions about the rubber dam to be the only adequate method of isolation
      European Society of Endodontology
      Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
      ,
      American Association of Endodontists
      Guide to Clinical Endodontics, Sixth Edition.
      , strikingly, many dentists used isolation methods below standard or gave no information of the use of any isolation. In our study, the patient documents revealed the use of matrix band for 12% of RCTs, whereas no other substandard methods were documented. In England, 29.4% of GDPs reported the use of cotton rolls,
      • Palmer N.O.A.
      • Ahmed M.
      • Grieveson B.
      An investigation of current endodontic practice and training needs in primary care in the north west of England.
      and in the United States, 12% of practitioners reported using cotton rolls all the time and 47% at least sometimes
      • Lawson N.C.
      • Gilbert G.H.
      • Funkhouser E.
      • et al.
      General dentists’ use of isolation techniques during root canal treatment: from the National Dental Practice-based Research Network.
      . Our data are insufficient in solving the dilemma, thus calling for new studies focusing on dentists’ actual clinical work and observing the underlying reasons for ignoring the clinical RCT practice guidelines. Dentists should warn patients about the risks associated with endodontics to obtain valid consent, as suggested by a director for the Centre for Endodontics in London, UK
      • Webber J.
      Risk management in clinical practice. Part 4.
      . Adherence to good clinical practice instructions and to detailed recording of treatments would also secure both public and private sector dentists against legal claims of possible errors.
      Among dentists specialized in endodontics, a broad consensus exists on guidelines given by endodontic associations for good endodontic practice. The question arises as to why GDPs so often question and even underestimate the guidelines for good clinical practice of RCTs and what tools and aids should be used to encourage GDPs to provide good endodontic care. Constructive suggestions shown here may help GDPs to strengthen their compliance with the RCT guidelines. Detailed recordings
      • King E.
      • Shekaran L.
      • Muthukrishnan A.
      Improving the quality of endodontic record keeping through clinical audit.
      of RCT and related checklists would be useful tools to help dentists to receive and maintain 100% compliance with the guidelines. Furthermore, incentives offered when use of the rubber dam is verified, may support compliance. Service management as well as individual patients could use our 4-item list as a tool for monitoring achievement of the keystones of the RCT process.

      Conclusion

      Deficiencies found in RCT, particularly underuse of rubber dams, call for further research to understand the reasons for noncompliance with good clinical practice guidelines and thus update RCT practices to their adequate adherence.

      CRediT authorship contribution statement

      Sini Leinonen: Conceptualization, Investigation, Resources, Data curation, Writing – original draft. Miira M. Vehkalahti: Conceptualization, Methodology, Formal analysis, Visualization, Writing – review & editing.

      Acknowledgments

      We acknowledge the Department of Social Services and Healthcare in Porvoo, for allowing us to collect our data from electronic patient documentation.
      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
      The authors deny any conflicts of interest related to this study.

      References

        • European Society of Endodontology
        Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology.
        Int Endod J. 2006; 39: 921-930
        • American Association of Endodontists
        Guide to Clinical Endodontics, Sixth Edition.
        (Available at:) (Accessed February 25, 2021)
        • Whitworth J.M.
        • Seccombe G.V.
        • Shoker K.
        • et al.
        Use of rubber dam and irrigant selection in UK general dental practice.
        Int Endod J. 2000; 33: 435-441
        • Eleazer P.D.
        • Gilbert G.H.
        • Funkhouser E.
        • et al.
        Techniques and materials used by general dentists during endodontic treatment procedures. Findings from the National Dental Practice-Based Research Network.
        J Am Dent Assoc. 2016; 147: 19-27
        • Ahmad I.A.
        Rubber dam usage for endodontic treatment: a review.
        Int Endod J. 2009; 42: 963-972
        • Ahmed H.M.A.
        • Cohen S.
        • Lévy G.
        • et al.
        Rubber dam application in endodontic practice: an update on critical educational and ethical dilemmas.
        Aust Dent J. 2014; 59: 457-463
        • Marshall K.
        ‘Dam it-it’s easy!’-or is it?.
        Br Dent J. 2017; 222: 839-840
        • Jenkins S.M.
        • Hayes S.J.
        • Dummer P.M.H.
        A study of endodontic treatment carried out in dental practice within the UK.
        Int Endod J. 2001; 34: 16-22
        • Lynch C.D.
        • McConnell R.J.
        Attitudes and use of rubber dam by Irish general dental practitioners.
        Int Endod J. 2007; 40: 427-432
        • Anabtawi M.F.
        • Gilbert G.H.
        • Bauer M.R.
        • et al.
        Rubber dam use during root canal treatment: findings from the Dental Practice-Based Research Network.
        J Am Dent Assoc. 2013; 144: 179-186
        • Lawson N.C.
        • Gilbert G.H.
        • Funkhouser E.
        • et al.
        General dentists’ use of isolation techniques during root canal treatment: from the National Dental Practice-based Research Network.
        J Endod. 2015; 41: 1219-1225
        • Markvart M.
        • Fransson H.
        • Bjørndal L.
        Ten-year follow-up on adoption of endodontic technology and clinical guidelines amongst Danish general dental practitioners.
        Acta Odontol Scand. 2018; 76: 515-519
        • Peciuliene V.
        • Rimkuviene J.
        • Aleksejuniene J.
        • et al.
        Technical aspects of endodontic treatment procedures among Lithuanian general dental practitioners.
        Stomatologija. 2010; 12: 42-50
        • Malmberg L.
        • Hägg E.
        • Björkner A.E.
        Endodontic infection control routines among general dental practitioners in Sweden and Norway: a questionnaire survey.
        Acta Odontol Scand. 2019; 77: 434-438
        • Helminen S.E.
        • Vehkalahti M.
        • Kerosuo E.
        • et al.
        Quality evaluation of process of root canal treatments performed on young adults in Finnish public oral health service.
        J Dent. 2000; 28: 227-232
        • Suominen A.L.
        • Helminen S.
        • Lahti S.
        • et al.
        Use of oral health care services in Finnish adults - results from the cross-sectional Health 2000 and 2011 Surveys.
        BMC Oral Health. 2017; 17: 78
        • Dahlström L.
        • Lindwall O.
        • Rystedt H.
        • et al.
        ‘Working in the dark’: Swedish general dental practitioners on the complexity of root canal treatment.
        Int Endod J. 2017; 50: 636-645
        • De Moor R.
        • Hülsmann M.
        • Kirkevang L.L.
        • et al.
        Undergraduate curriculum guidelines for endodontology.
        Int Endod J. 2013; 46: 1105-1114
        • Laukkanen E.
        • Vehkalahti M.M.
        • Kotiranta A.K.
        Impact of type of tooth on outcome of non-surgical root canal treatment.
        Clin Oral Investig. 2019; 23: 4011-4018
        • Webber J.
        Risk management in clinical practice. Part 4.
        Endodontics. Br Dent J. 2010; 209: 161-170
        • Gilbert G.H.
        • Riley J.L.
        • Eleazer P.D.
        • et al.
        Discordance between presumed standard of care and actual clinical practice: The example of rubber dam use during root canal treatment in the national dental practice-Based research network.
        BMJ Open. 2015; 5: 1-8
        • American Association of Endodontists
        AAE position statement: dental dams.
        (Available at:) (Accessed February 25, 2021)
        • Palmer N.O.A.
        • Ahmed M.
        • Grieveson B.
        An investigation of current endodontic practice and training needs in primary care in the north west of England.
        Br Dent J. 2009; 206: E22
        • King E.
        • Shekaran L.
        • Muthukrishnan A.
        Improving the quality of endodontic record keeping through clinical audit.
        Br Dent J. 2017; 222: 373-380