Patients’ perceptions and experiences about the root canal treatment: An exploratory study among Saudi population

INTRODUCTION

Root canal therapy is one of the most popular treatments at dental setting^[1] and treatment for irreversible pulpitis has been generally acknowledged.^[2] However, it is one of the dental procedures that cause maximum patient anxiety and pain compared to the other dental procedures.^[3] Dental pain is a great source of anxiety and a significant problem for dentists.^[4] Therefore, managing pain and anxiety are a difficult in the clinical practice of endodontics and are the key factor on which the clinician’s ability is also measured.^[1] The International association for the study of pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.^[2] Whereas dental anxiety is defined as patient’s specific reaction toward stress related to the dental treatment in which the stimulus is unknown, vague, or not present at that moment. Around 2.5–20% of people suffer from high dental anxiety, based on study population under study and technique used for anxiety measurement.^[5] In several countries around the world the constant existence of dental anxiety for various dental procedures has been reported.^[6] Approximately 67–80% of Americans were rated extremely anxious about dental care and 5–14% of them were rated as severely anxious.^[3,5] The prevalence of dental anxiety among Australians was recorded to be 14.9%, with 12.5%, and 12.6%, respectively, among young adults in Canada and teenagers in Russia. There is some sort of dental anxiety around 13.5% of the French population and 30% of the Chinese population. In KSA few studies on the prevalence of dental anxiety were performed. A research conducted in Riyadh in adolescent females to determine dental fear and anxiety found that 29% of participants had high rates of anxiety. Al-Shammary et al.^[7] carried out a study in which 11.8% of the respondents surveyed viewed dental care as a painful process.^[6]

Dental anxiety and fear appear to differ from treatment types. Periodontal or endodontic procedures have shown to be more anxiety than restorative or prophylactic procedures.^[5,7,8] Recent research shows there are variations between men and women in experiences of pain. While most studies indicate women have greater sensitivity to pain than men, but there are discrepancies in the literature.^[9] It was found that major concern of dentist is anticipated and experienced pain from root canal treatment (RCT). Before treatment, during treatment, and post-treatment pain is anticipated experienced recalled and shared by patients.^[8] Various authors have suggested that social, psychological, and behavioral factors such as awareness, values, perceptions, desires, and behavior can affect the patients decision for dental care and their satisfaction after treatment.^[7,10] Many of the variables analyzed in the past studies include the socioeconomic status of patients, educational level, quality of life and health background, aspirations, and past dental experiences objective or subjective. Any of these factors as well as misunderstandings regarding the treatment protocol are often cited as explanations for people to opt out of RCT.^[11] which not only poses a risk to the patient’s oral health but also poses serious medical conditions such as septicemia, sinusitis, and osteomyelitis.^[12]

Despite technical advancements in dentistry, anxiety about dental care and the fear of dental pain remain widespread worldwide and are considered a major barrier to dental care.^[12] Based on previously published data, educating patients about anticipated post-endodontic pain and prescribing medicines to manage it can increase patient trust in their dentists, raise pain thresholds and improve their attitude toward future dental care.^[13] Janczarek et al.^[14] in his study reported that there is an increase in patient knowledge and understanding of endodontic care^[15] if pain risk factors that can be assessed before initiation of treatment could be identified, dentists may use this knowledge to preoperatively classify patients at elevated risk and adopt proactive measures to alleviate pain and mitigate patient discomfort.^[16] However, the extant literature containing data on endodontic pain is rather disparate and primarily includes articles focusing on other topics, typically prognostic variables, treatment variables, or medications. Direct comparisons of pre-treatment, treatment, and post-treatment pain are extremely rare in Saudi Arabian context. Hence, the present research undertaken to assess the outpatient’s perception and experience about RCT and compare their experience post-treatment.

MATERIAL AND METHODS

The present study was undertaken after the approval of institutional ethics committee at college of Dentistry, Qassim University (Ethical Committee clearance document number: ST/53/2018). Duration of study was decided to be 6 months to complete the enrolment of required number of participants.

Study instrument

In the present study, participants were asked to provide their response toward the endodontic treatment before and after the treatment. To record the response, pre-validated pre-test and post-test questionnaire developed by Chandraweera et al. (2018)^[3] were used as shown in Figures 1 and 2. These questionnaires consisted of demographic data of patient like age, sex, and educational status. Further questionnaire included specific information related to RCT. These questions were mainly targeted to measure patient’s anxiety, concern about RCT, experience of pain which was recorded by Modified Visual Analog Scales (0–100%),^[3] cost of treatment, and feedback on re-treatment. The questionnaire was self administered, and to get the valid response, questionnaire was translated into Arabic language by native speaker using forward and back translation method. Further reliability of questionnaire was checked by test retest method and necessary correction was made.

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Figure 1:

The pre-treatment survey form.^[3]

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Figure 2:

The post-treatment survey form.^[3]

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RESULTS

The present study was conducted among the group of cohort attended the college of dentistry. Out of 105 participants, 76 participants were selected depending on inclusion criteria and completed the pre- and post-treatment surveys. Table 1 demonstrates the demographic profile of the study participants, 43 (56.6) were males with mean age of 20.53 ± 10.98 while 33 (43.4) were females of 26.45 ± 7.27 age. All the participants irrespective of gender in the present study were educated with the highest level of education was university followed by secondary school, middle, and primary school.

In this study, participants were asked different sets of question before the start of RCT and at end of the treatment to know insight of patient towards RCT which is presented in Table 2.

Initially, the participants concern about RCT was recorded, patients with no concern for RCT before treatment 10 (6.6) were found significantly concerned about the RCT after post-treatment 40 (26.3). Similarly concern for pain associated treatment and cost of treatment was significantly decreased from pre-treatment (29 [19.1]; 10 [6.6]) to post-treatment (14 [9.2]; 2 [1.3]), respectively.

Further, patient’s anxiety score was assessed which was found to be significantly decreased from pre-treatment 31.47 ± 28.90 to post-treatment 23.28 ± 25.95. Likewise, mean anticipated and experience of pain score were also significantly reduced pre-treatment 41.07 ± 29.35 to post-treatment 21.90 ± 24.50. It was found that patients with the previous history of RCT and currently suffering from pain, anticipated pain pre-treatment, and it was found slightly painful. However, patients who had previous experience about RCT showed the slightly high importance for keeping the tooth in mouth by treating rather than going for extraction.

After RCT, patients were asked various questions to record their change of attitude toward the RCT. The majority of patients reported improvement (75.93 ± 24.70) in their experience for RCT than previous experience. Moreover, patient found happy to keep their tooth rather than removed it. The majority of patients 65 (85.5) responded that they prefer the RCT rather than removal of tooth and 74 (97.4) were overall satisfied from RCT. Further comparison of pre- and post-treatment means anxiety score and anticipated pain and experience pain were compared with gender but there was no significant difference was found [Table 3].

DISCUSSION

This study was carried out at Dental clinics of Qassim University from September 2019 to March 2020. The study consisted of 76 patients who visited the clinic for RCT and fulfilled the inclusion criteria of study. RCT is most commonly performed and demanding procedure at dental clinic. It not only saves the tooth but undeniably improve the quality of life. Yet the decision to treat patient was highly subjective in nature and could be influenced by multiple factors such as community, employment, socioeconomic status, values, and practices.^[11]

In addition, dental patients today are less tolerant of pain that induces procedures and RCT is one no exception to this. To maximize clinical success, pain during RCT must be controlled preoperatively through correct diagnosis and reduction of anxiety.^[1] Since dental anxiety, fear of unknown variables is highly affects patient decision-making and based on the experience felt. Various literature studies have indicated that, in fact, the nervous or anxious patient is more likely to recall the pain and expect the same experience^[16,17] which leads to less utilization of health services.^[5]

Recent experimental research focused on directed pain stimuli showed that negative anticipation induces anxiety that can intensify the actual pain.^[9] Rhudy and Meagher recommended to pre-treatment anxiety correction as a best practice.^[18]

There are few studies in literature that analyze the pain experience before during and after treatment. The present study sought to provide further information to the patient and dental health-care provider to practice the endodontic treatment in better way.

CONCLUSION

Current study reported a significant difference in reduction of mean anxiety for RCT post-treatment. Moreover, there was significant difference found between anticipated pain and experienced pain for the treatment. Before the treatment significant number of patients were not concerned for RCT and majority of patients were concerned for pain associated to RCT. These both concerned were significantly reduced post-treatment. Overall patients showed positive response to RCT post-treatment and provided extremely satisfied inputs. Despite of all positive points the present study reported a few limitations. Although the cost of treatment was not concerned about patients, still further exploration regarding different socioeconomic status would have been done. Small sample size made many explorations undone hence it is recommended to perform further research by involving larger sample size.