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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 267-271

Confidence level and experience of undergraduate students toward root canal preparation using rotary versus manual root canal instrumentation: Preliminary study

Department of Restorative Dentistry, Faculty of Dentistry, University of Medical Sciences and Technology, Khartoum, Sudan

Date of Submission28-Jul-2021
Date of Decision26-Aug-2021
Date of Acceptance29-Sep-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Elhadi Mohieldin Awooda
Department of Restorative Dentistry, Faculty of Dentistry, University of Medical Sciences and Technology, P. O. Box 12810, Khartoum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_132_21

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Background: The assessment of experience, difficulties encountered, and comparison of root canal preparation using manual versus rotary technique among undergraduate students is needed. Objectives: The aim of this study was to evaluate the perception of undergraduate dental students' first-time experience using Nickel–Titanium rotary instruments for root canal treatment. Materials and Methods: A descriptive cross-sectional study among 26 final year undergraduate dental students of batch 15 (2014–2015) from the University of Medical Sciences and Technology, Sudan. A self-administered questionnaire composed of two parts; in the first part the questions were relating to the students' confidence levels and experience of clinical root canal treatment using both rotary and manual instruments, while the second part focused on the comparison between rotary and manual instrumentation; difficulties encountered, complications, and preferences. The Chi-square test was used for comparison between different variables with the level of statistical significance set at P ≤ 0.05. Results: The majority (80.8%) had a satisfactory first-time experience when using rotary instruments in the root canal treatment of their patients. When using rotary, 26.7% of students experienced separated instruments, and 30% experienced over-preparation. However, the most common complications arising with the use of a manual instrument was ledge formation (23.4%). The most common canal in which separation of instruments occurred was the mesiobuccal canal of molar teeth with percentages of 72.7% for rotary and 52.9% for manual. The most commonly separated rotary file was S1 Protaper (77.8%). Conclusion: The majority of the undergraduate students had a satisfactory experience when using rotary instruments for root canal treatment. A high prevalence of complications was associated with the use of either rotary or manual technique. The most common complication was the separation of the instrument in the mesiobuccal canal of molar teeth.

Keywords: Confidence level, hand instrumentation, protaper system, rotary Ni-Ti, undergraduate dental students

How to cite this article:
Awooda EM, Elmahgoub FA, Al-Nazhan SA. Confidence level and experience of undergraduate students toward root canal preparation using rotary versus manual root canal instrumentation: Preliminary study. J Dent Res Rev 2021;8:267-71

How to cite this URL:
Awooda EM, Elmahgoub FA, Al-Nazhan SA. Confidence level and experience of undergraduate students toward root canal preparation using rotary versus manual root canal instrumentation: Preliminary study. J Dent Res Rev [serial online] 2021 [cited 2022 Dec 3];8:267-71. Available from: https://www.jdrr.org/text.asp?2021/8/4/267/332920

  Introduction Top

When considering the future of dental education; students can provide valuable feedback on their perception of dental education to improve the learning environment and the overall standard of training, as well as patient care.[1],[2],[3] The status of the undergraduate teaching of endodontics and confidence in performing root canal treatment should be raised to guarantee an improvement in daily clinical practice.[3],[4]

Many investigations comparing hand versus rotary root canal preparation have been published.[5],[6],[7],[8],[9],[10] Experimental and clinical evidence of these studies suggested a better preparation quality and accuracy with the use of Nickel–Titanium (Ni-Ti) instruments. In addition, an inexperienced operator has been shown to produce a higher rate of clinical success than a hand filing technique.[11],[12] Despite the several reports that have been published, indicating low rates of complications,[9] the introduction of Ni-Ti rotary instruments into undergraduate training has been met with some resistance.[13] There may be many reasons for this, including the risk of instrument fracture, lack of experience, and their high cost.[9]

In the academic year 2014–2015, for the first time in Sudan, the clinical use of rotary Ni-Ti was introduced to 5th year undergraduate dental students of batch 15 (University of Medical Sciences and Technology [UMST]), which ran parallel with manual preparation. Certain requirements were set, and all the students were requested to treat at least two teeth using rotary Ni-Ti specifically through the Protaper system (Maillefer, Baillaguess, Switzerland). The requirement for root canal treatments set by the department has followed the recommendation of the European Society of Endodontology.[3] The Endodontic subject is taught over the final four semesters, during the fourth and 5th year of training course. The students begin their Endodontic preclinical training in semester 7, by treating seven extracted teeth. The techniques used include manual instrumentation by means of the step-back technique and crown-down technique using rotary files. Then from semester 8, they proceed to treat patients after having been deemed competent. The requirements are as follows; two teeth (anterior or premolar teeth) for semester 8, then 12 teeth (four anterior, four premolars, and four molars) for both semesters 9 and 10.[14] At least two premolar or molar teeth should be prepared by rotary files through the Protaper system. The time duration allocated for the Endodontic clinic is 3 h/week with abundant close supervision by the staff members in a ratio of 1:4 (staff: students).[15] To ensure competent supervision and sufficient time to acquire skills, students are informed that their clinical requirements are to be finished within semester duration, with an average of three visits per root canal treatment per single tooth.[14] For the graduation summative assessment, students were requested to perform single-visit root canal treatment (RCT) for a premolar tooth using hand files without any supervision and should finish the competency in 3 hours duration. Students were not allowed to sit for the final semester 10 (BDS) written examination unless they fulfilled the requirements and passed the competency exam. During the final BDS Endodontic examination, each student should present his/her treated clinical cases using a PowerPoint program in the presence of internal and external examiners (the external examiner for the academic years 2015, 2017, and 2018 was the coauthor; Alnazhan SA ). In this study, when the three learning domains were considered for student assessment, we did not assessed their psychomotor skill in RCT, but we assessed their cognitive and attitude skills in performing RCT using manual versus rotary canal preparation technique and their knowledge on how to manage, if complications encountered.

It is interesting to evaluate the students' perception regarding the newly introduced technique and to assess the experience gained to be able to improve the quality of root canal treatment through the introduction of the rotary files technique during the preclinical and clinical course. It was hypothesized that the result obtained from this study could be used for further curriculum development of Endodontic Subject in this University and others as there were no previous studies tackling this issue in Sudan. Therefore, the objective of this study was to evaluate the confidence level of the 5th year undergraduate dental students' clinical experience using rotary Ni-Ti systems for root canal treatment: their insight, difficulties encountered, complications, preferences, and comparing it with their experience in using the manual instruments.

  Materials and Methods Top

A descriptive cross-sectional study among final year undergraduate dental students from UMST, Sudan. The study conducted during the last week of the academic year (2014–2015) final semester 10 in the Academy Dental Teaching Hospital (UMST), Khartoum, Sudan. The total number of this batch was 26 (male and female students), and all participated in the study. For this study, each student, after finishing his/her case presentation was informed of the objectives of the study and requested to participate voluntarily. Each student was requested to sit at a prepared area at the nearby clinic to answer the self-answer questionnaire, which was closed-ended questions. These questions were related to the Student's confidence level and clinical experience of root canal treatment using both manual and rotary instruments. The first part of the questionnaire showed the students' satisfaction and confidence towards the use of rotary instrumentation, while the second part; focused on the comparison between rotary and manual instrumentation in relation to the duration of time allocated to finish preparation, easiness, and difficulties in handling the instruments, complications or procedural errors (separated instruments, perforation, over instrumentation, or ledge formation). The level of confidence was assessed by Likert's scale system as Very little confidence, little confidence, Neutral, Confident, and very Confident.[16]

A pilot testing of the questionnaire was carried on the first seven students who presented their cases and requested to answer questions and handed it to the second author (FM). FM assessed comprehensibility and reliability, with some questions been altered accordingly, corrected by the piloted participants, and included in the final revised questionnaire. Those seven students were included in the final study due to the small number of participants so as not to jeopardize statistical tests used and to avoid false-positive error.

Ethical consideration

The study was approved by the Ethical Committee of the UMST (IRB approval number is 03/15). Their names and identities were anonymous, and all the students agreed to participate voluntarily and signed informed written consent. The data were kept confidential and only used for the purposes of the study.

Statistical analysis

The questionnaires were numerically coded, and the data were processed and analyzed using the computer software statistical program SPSS (Statistical Package for Social Sciences) version 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis carried out using the Pearson Chi-square test for correlation of nonparametric data. The level of statistically significant difference was set at P ≤ 0.05.

  Results Top

All the questionnaires were completed, and the data obtained were analyzed to provide descriptive statistical results. When considering the number of treated cases by rotary instruments, it revealed that students prepared single tooth were (23.1%), 50% prepared 2 teeth, 19.2% prepared 3 teeth, 3.8% prepared 5 teeth, and 3.8% prepared 9 teeth. Of the 26 students, 21 (80.8%) had a satisfactory experience when using rotary instruments. When asked whether any difficulty was experienced during preparation using rotary Ni-Ti instruments, 34.6% had no difficulty, 50% had little difficulty, and 15.4% had great difficulty.

When students passed the first experience of Ni-Ti rotary instruments, the percentage of the level of confidence altered slightly as displayed in [Table 1].
Table 1: Level of confidence when using rotary Nickel-Titanium instruments for the first time and after the first time experience

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When comparing the speed and comfort of rotary instruments versus manual instruments, 88.5% indicated that the rotary Ni-Ti system provided better speed and comfort when compared with the manual. More than half (61.5%) experienced one or more complications when using rotary instruments.

[Table 2] revealed a comparison of various complications experienced by the students when used rotary Ni-Ti instruments and manual instruments. Manual preparation of the root canal causes more mishaps. The incidence of ledge formation was higher when manual instrumentation was used compared to rotary (P = 0.265) as well as apical transportation (P = 0.0860) and over-preparation (P = 0.873).
Table 2: Complications experienced when using rotary and manual instrumentations

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In comparison, the main reason for instrument separation when using hand or rotary instruments for canal preparation is displayed in [Table 3]. Inexperience and lack of skill (P = 0.750), over usage of the instrument (P = 0.606) and poor quality of the used instruments (P = 0.365) were the main reasons behind instrument separation.
Table 3: The reasons behind the experience of separated Instrument when using rotary or hand canal preparation

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The most common canal in which separation of instruments occurred was the mesiobuccal canal of molar teeth; (72.7%) in rotary, and (52.9%) with manual use, while the most commonly separated rotary file was S1 Protaper (77.8%).

After completing root canal treatment by rotary files, 16 students (61.5%) were satisfied with the quality of RCT, while 10 students (38.5%) were not. More than half (57.7%) of the students stated that the quality of obturation was more satisfactory after preparation with rotary instruments.

  Discussion Top

The step-back technique had been the principal method used in root canal preparation over the past four decades, and Klayman and Brilliant[17] and Walton[18] have described the basic principles of this technique. Many significant problems have been noted by Allison et al.[19] and Eideeb and Boraas[20] with the use of the step-back technique. With the development of Endodontics and the introduction of Ni-Ti, instruments by Walia et al., 1988 newer and more advanced techniques have been established.[21] The introductions of rotary Ni-Ti instruments have been a significant advancement in the area of endodontics due to the improved treatment outcome and predictability involved with the use of these instruments for root canal preparation.[5]

The utilization of rotary instruments in the undergraduate endodontic training is still met with resistance in the universities across Sudan; however, the rotary technique using ProTaper files has now been introduced into the undergraduate Endodontic program in the UMST since 2014. It is the first dental school in Sudan to set obligatory requirements for the students to treat at least two teeth. Preclinical and clinical training on the use of Ni-Ti rotary files goes parallel with the manual files. The main reason for not using rotary instruments in Sudan, like others; may be due to the lack of training,[22] expansiveness, and unavailability of these rotary handpieces and files. This further signifies the importance of including the teaching of rotary methods in preclinical and clinical undergraduate endodontic courses, and the universities should be obligated to provide equipment and facilities for a better educational environment.

In our study, majority of students had a satisfactory experience when using Rotary Ni-Ti instruments. This corroborated the results of some other studies[6],[9],[11],[23] which observed that inexperienced students used rotary Ni-Ti files with success and achieved good root canal geometry, as well as having less transportation and faster preparation times. However, other studies concluded that hand instruments may be safer for inexperienced students.[24] In contrast to Puryer et al,[6] the result by Nouman et al.,[9] is comparable to our results when the subjective satisfactory first-time experience of rotary Ni-Ti files is considered to be high.

Inconsistent with our study, it has been reported that a high number of file breakages was linked to the use of rotary instrumentation by undergraduate students[9] as well as experienced Endodontists and general dentists.[23] While Gekelman et al., 2009, showed that, Ni-Ti files performed adequately with inexperienced novice operators that had received a brief structured training session.[24] The majority of our students completed 2 cases using rotary systems; this may have been the reason for the obtained results. There is, however, a statistically significant difference between the complications arising when using the rotary instruments as compared to the manual instruments; this contradicts with the results reported by f Abu-Tahun et al.[25] The main reasons associated with file fracture were overuse and excessive pressure, and the main reason mentioned for not using rotary Ni-Ti instruments was a lack of training. We think the financial burden for both students and the university may be another reason.

In our study, the most commonly fractured file was S1 Pro Taper, the early fracture of this canal shaper may change the plan of treatment, which contradict to F1 in Ünal et al., results,[23] but agreed with Peng et al.,[26] who evaluated defects on Protaper S1 instruments after a defined schedule of clinical use. They found that multiple uses of ProTaper S1 predisposed the instrument to micro-crack formation and wear of the cutting edges as agreed with Vieira et al., 2011, who revealed that lateral pressure motion reduces the maximum torque for the Pro-taper S1 and S2 instruments.[27] A study by Bruno et al., (2016) showed no significant difference between Protaper file types with a low fracture rate of 0.37%.[28] Most ProTaper S1 instruments failed without discernible signs of an unwinding of the flutes. This may be related to the problem in the manufacture of these files, along with the zealous application of pressure, lack of experience, and overuses.[29]

Although the prevalence of separated rotary instruments is less than that of the manual instruments, this may be attributed to the fact that more cases were completed using the manual preparation technique, while the majority of the students only completed 2 cases using rotary systems, and therefore a more comprehensive comparison may be required in the future.


The performance of rotary and manual instrumentations between male and female students was not compared as the ratio of male to female will affect the analysis even if we used a quota nonprobability technique because the number of male students in this batch was only four. The most separated manual file, its size, and the number of its use were not controlled. Furthermore, the personal skill was not adjusted for the occurrence of preparation mishap. Because our main objective of this study was on assessing the confidence level when using rotary versus manual, so the external validity will be affected, and generalization of the results should be considered with caution.

  Conclusion Top

Confidence level in using rotary files was considered high after students performing RCT by both manual and rotary. It is clear that there is a high prevalence of complications associated with the use of rotary files, where separated instruments being the main. Much more emphasis should be focused on teaching rotary endodontic during the preclinical and clinical courses, and this should be a part of the curriculum development in Endodontic education.

Ethical clearance

The study was approved by the Ethical Committee of the UMST (IRB approval number is 03/15).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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