|Year : 2014 | Volume
| Issue : 4 | Page : 471-478
Knowledge and attitudes of Turkish endodontists towards digital radiology and cone beam computed tomography
S Ercalik Yalcinkaya1, Y Garip Berker2, S Peker3, FB Basturk2
1 Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Marmara University, Istanbul, Turkey
2 Department of Endodontics, Faculty of Dentistry, Marmara University, Istanbul, Turkey
3 Department of Paediatric Dentistry, Faculty of Dentistry, Marmara University, Istanbul, Turkey
|Date of Acceptance||25-Sep-2013|
|Date of Web Publication||6-Jun-2014|
S Ercalik Yalcinkaya
Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Marmara University, Buyukciftlik sk. 6 Nisantasi, 34365 Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The aim of this study was to assess the knowledge and attitudes of Turkish endodontists toward digital radiological imaging (DRI) and cone-beam computed tomography (CBCT).
Materials and Methods: One hundred and fifty questionnaires were distributed. Questionnaires were given to a sample of endodontists and PhD students in endodontics who attended the 11 th International Congress of the Turkish Endodontic Society in Istanbul in 2012. Following the congress, the same questionnaires were sent electronically to endodontists who did not attend the congress. The participants were asked to answer 28 multiple-choice questions concerning their knowledge and practice regarding recent imaging techniques. The questions were subdivided into 2 main topics; general information; general approach to digital imaging. The statistical analysis was carried out by an χ2-test to compare the means at a significance level of P < 0.05.
Results: The response rate for this study was 74%. The mean age of the endodontists who participated in this study was 32.74 ± 10.40 (range 22-61 years). Of the endodontists, 76.6% used digital imaging techniques (DUEs) in their clinics. Statistically significant differences were found between the DUEs and endodontists not using digital imaging (NDUEs), regarding age, gender, graduation year and place of employment ( P < 0.01). Endodontists 40-years-old and above had significantly lower knowledge of CBCT compared to the younger groups ( P = 0.001).
Conclusions: The number of endodontists using digital imaging has been increasing in Turkey. The findings of the present study highlighted the need for adapting to new technologies via continuing education.
Keywords: Cone-beam computed tomography, digital imaging, knowledge, questionnaire
|How to cite this article:|
Yalcinkaya S E, Berker Y G, Peker S, Basturk F B. Knowledge and attitudes of Turkish endodontists towards digital radiology and cone beam computed tomography. Niger J Clin Pract 2014;17:471-8
|How to cite this URL:|
Yalcinkaya S E, Berker Y G, Peker S, Basturk F B. Knowledge and attitudes of Turkish endodontists towards digital radiology and cone beam computed tomography. Niger J Clin Pract [serial online] 2014 [cited 2017 Mar 23];17:471-8. Available from: http://www.njcponline.com/text.asp?2014/17/4/471/134044
| Introduction|| |
Researchers have investigated the use of digital radiological imaging (DRI) in various countries. In 2000, it was estimated that 5% of dental practitioners in North America used digital radiography in their practice.  In studies conducted in Norway, the usage rate was estimated to be 11-14% , and in the Netherlands it was estimated as 12%.  In an earlier study conducted in the state of Indiana, USA,  19.7% of dental practitioners indicated that they were using digital radiography, whereas in the aforementioned study, two out of four endodontists reported that they were using digital radiography.
Digital radiography has been used increasingly for over a decade in Turkish dental practices ,, In a previous study conducted in Turkey, 67% of dentists and 96% of academics indicated that they used DRI, and 55.9% of dentists and 79.1% of academics had knowledge about cone-beam computed tomography (CBCT).  In that study, dentists' knowledge and practices in dental radiology were not evaluated according to their specialties; therefore, it was not possible to predict the frequency of the use of DRI amongst endodontists.
Dental radiology has always played a major part in endodontics. Traditionally, radiography is used to evaluate pre-, intra-, and post-treatment of patients.  Recent improvements in digital dental radiology have included not only technological advances but also enhanced resolution of images, which is of great importance in endodontics since only high-quality images show canal morphology and periapical area accuratel. ,, To provide three-dimensional imaging, use of CBCT was proposed in the practice of endodontics and a joint position statement by the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology was announced. For most endodontic applications, limited-volume CBCT has been recommended. Although CBCT is limited to the diagnosis and treatment of only more complex endodontic conditions, it remains the method of choice compared to two-dimensional imaging. 
General dental practitioners in Turkey perform root canal treatments on a daily basis.  Previous studies have included general dentists and specialists of various fields, but no study has investigated the use of digital imaging and CBCT, specifically by endodontists. Thus, the primary objectives of this study were (1) to determine the prevalence of DRI and CBCT usage in Turkish endodontists and their accompanying reasons for using or not using digital radiography and CBCT, and in addition, (2) to assess their degree of knowledge regarding new imaging systems and their need for education in that area.
| Materials and Methods|| |
A total of 150 questionnaires were distributed. The questionnaire was developed with guidance of previous studies. ,,,, Seventy questionnaires were given to a sample of endodontists and PhD students in endodontics, who attended the 11 th International Congress of the Turkish Endodontic Society in Istanbul in 2012 [Figure 1]. Following the congress, the same questionnaires were sent electronically to 80 endodontists who did not attend the congress. The participants were asked to answer 28 multiple-choice questions. The questions were subdivided into 2 main topics:
- Demographic data: Age, gender, years of professional experience, working situation (e.g. PhD student, private practice, university)
- General approach to digital imaging: Use of digital imaging and radiographic equipment, methods, knowledge and practice of digital imaging.
Multiple responses were allowed in five questions. Other questions in the survey used a five-point Likert answer scale: 'never', 'rarely', 'sometimes', 'very frequently', and 'always' as well as 'strongly disagree', 'disagree', 'neither agree or disagree', 'agree' and 'strongly agree'.
A total of 111 questionnaires consisting of 28 questions were available for analysis. The collected data was entered into a personal computer and analyzed using Statistical Package for the Social Sciences (SPSS) software version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Data was evaluated according to descriptive statistics, which are presented as frequencies (n) and percentages (%). A chi square test was used to determine the significance of differences between age/years of experience in endodontics and knowledge. The level of significance was set at 5%. Unanswered questions were treated as missing values.
| Results|| |
The response rate for this study was 74%. From the 150 questionnaires distributed, 111 were deemed usable. Fifty-two out of 70 questionnaires were collected during the congress. Of the 80 questionnaires sent electronically to the endodontists who did not attend the congress, 69 responses were gathered.
The mean age of the endodontists who participated in this study was 32.74 ± 10.40 (range 22--61 years). The demographic characteristics of the endodontists are shown in [Table 1]. Most of the endodontists had 1-10 years of professional experience (10.33 ± 10.36 years; range: 1-37 years, median: 6 years). It was noted that 53.2% of the endodontists were working at a university and 11.7% were PhD students (at a university). Only 18.9% were private endodontic practitioners and 16.2% were employed at hospitals or dental clinics.
Use of digital imaging
The majority of the respondents (76.6%) reported using digital imaging. Statistically significant differences were found between digital imaging using endodontists (referred to as DUEs) and endodontists who did not use digital imaging (NDUEs) regarding age, gender, years of professional experience and type of practice (P < 0.01), [Table 1].
|Table 1: Demographic data of the endodontists and statistical evaluation of endodontists using digital imaging and not using digital imaging |
Click here to view
The reason (s) for using and not using DRI are shown in [Table 2]. According to age and type of practice, no statistically significant difference was found regarding the reasons other than the given reason 'image settings and measurements are possible'. This answer was found to be statistically significant in the 20-29-year-old DUEs group (P = 0.005). When the same question was analyzed according to years of professional experience, only the reason 'relatively lower radiation dose' was found to be statistically significant in the 40-year-old and greater DUEs group (P = 0.046). There was no statistically significant difference between male and female endodontists regarding the reasons to use digital imaging.
On evaluation of the reasons 'not to use DRI', there were no statistically significant differences according to age, gender and type of practice. Only the reason 'being expensive' was found to be statistically significant in the groups of graduates over 10 and 20 years of age (P = 0.036).
Fifteen of twenty-six (57.7%) of the NDUEs indicated that they planned to frequently use digital imaging techniques in the future.
Of the DUEs, 95.3% used periapical radiography, whereas 71.8% used panoramic radiography for digital imaging. The frequency of use of DRI was indicated as 'always; 77.6%' and 'very frequently; 20%' by the DUEs. 75.3% of the DUEs found the quality of the digital images satisfactory.
Of the DUEs, 63.5% stated that digital imaging increased the number of repetitions of film taking. Moreover, 45.9% of the DUEs had difficulty placing the oral digital sensors. Of the DUEs, 25.9% were using smaller sensors for pediatric patients.
Use of radiology equipment
The dental X-ray devices used by the DUEs were generally new: Up to 7 years old (77.6%) and 7-15 years old (20%). Only one respondent's device was more than 25-years old.
Of the DUEs, 56.6% had panoramic X-ray equipment in their clinics, 10.4% of which were conventional film, 43.8% were photostimulable storage phosphor (PSP), and 45.8% were charge-coupled device or complementary metal oxide silicon (CCD/CMOS) sensor systems. Only 15.3% of the DUEs said that they used a film holder when taking digital images. Of the DUEs, 88.2% set the exposure time to be shorter than with conventional radiography.
Only 25.7% of endodontists reported that their X-ray units had been serviced routinely, 31.1% occasionally, and 43.2% never serviced their X-Ray units.
Methods of digital imaging
Use of various sensors for digital imaging is shown in [Table 3]. Of the DUEs, 70.6% were PSP users, 25.9% were CCD/CMOS users, and 3.5% used both. A statistically significant difference was found between the imaging systems used and type of practice. Use of SPS was found to be relatively higher than CCD/CMOS in the group of PhD students and academics (employed at a university), (P = 0.006).
|Table 3: Use of digital sensors according to age, type of practice and years of professional experience |
Click here to view
Eighty percent of the DUEs stated that if they were to buy a new digital imaging system, they would prefer the PSP.
Knowledge and practice of CBCT
Of the endodontists, 66.7% stated that they had knowledge of CBCT. Of this group, 41.9% said that they had referred their patients for CBCT before. Regarding the dose reduction, 62.2% knew the difference between CT and CBCT.
Reasons for referring patients to CBCT were stated as: Cyst-tumor; 82.4%, implant planning; 71.6%, trauma; 50%, to indicate the resorption area; 32.4%, to examine the morphology of the root canal; 25.7%, to detect the exact place of broken files; 16.2%.
There was no statistically significant difference between male and female endodontists according to previous knowledge of CBCT. When years of professional experience were evaluated, endodontists over 40 years of age had significantly less knowledge of CBCT than younger endodontists (P = 0.001). Academics and PhD students in endodontics had significantly greater knowledge of CBCT compared to the endodontists working in private practice and clinics (P = 0.002), [Table 4].
|Table 4: Endodontists' knowledge of CBCT according to demographic distribution |
Click here to view
Of the endodontists, 66.2% indicated that they updated their knowledge by attending congresses, 12% by conferences and continuing education courses with credits, 55.4% via internet, 55.4% by reading books and journals, and 37.8% by materials provided by company representatives.
| Discussion|| |
This study gathered information about the attitudes of Turkish endodontists toward DRI. The endodontists mentioned in this study were either attendees of the 11 th International Congress of the Turkish Endodontic Society or the members of Turkish Endodontic Society whose e-mail addresses were accessible electronically. The number of members of Turkish Endodontic Society was reported as 331,  approximately three quarters of which are actively working. For these variables, we can accept that the distribution of the present sample is representative for the total Turkish endodontic population. The questionnaire was developed with guidance of previous studies. ,,, Response rate was similar to the study conducted in the Netherlands  and was relatively higher compared to the one in the USA. 
Radiology is an integral part of endodontic practice and is recognized as a main diagnostic aid.  It enhances the quality of endodontic treatment and shortens the duration of root canal treatment procedures. ,,, Several digital radiographic systems are currently used in dental practice as an alternative to film-based radiography. In the last decade, both PSP and CCD or CMOS sensor systems have frequently been used by endodontists for intraoral examination. Recent improvements and continuing development of sensor technology have made higher-resolution images possible. Furthermore, algorithms offered by software systems enhance the image for various diagnostic purposes. ,
Several studies have evaluated the popularity of DRI since the adoption of digital radiology in dental offices. One study reported that 14% of dental practitioners chose using digital radiography,  but subsequent studies reported a higher percentage. , Surveys conducted amongst Belgian general dental practitioners reported that the rates of DRI use are of 34% (18% PSP, 16% CCD) and 38%. ,
Over the last few years, introduction and sales of digital systems in Turkey have increased. In a study conducted in Turkey in 2005, Ilgόy et al.,  showed that DRI was used by 14% of dental clinicians.  In a recent report from Dolekoglu et al.,  it was noted that the rate of use of digital radiology as an aid has increased to 67%. 
Previous reports focused on the use of DRI in different groups of general dentists, but none assessed endodontists, despite their frequent use of DRI. This fact should be kept in mind when comparing our results with previous reports. This study revealed that 76.6% of Turkish endodontists used DRI, indicating its popularity in this group. However, DRI use seemed to depend on the advances of dental faculties, since academics and PhD students in endodontics were the main groups participating in the questionnaire. Of endodontists employed at the university, 91.5% indicated that they have used digital systems routinely, as did 84.6% of PhD students.
Similar to the findings of Brian and Williamson,  "no developing process" (81.2%) was stated as the most important factor for choosing digital radiography, followed by being easy and rapid to maintain (78.8%).
Fifty percent of the NDUEs stated price to be the most important reason for not choosing DRI. This finding is in agreement with previous studies. ,,, In contrast to previous reports, , significant differences were observed between the DUEs and NDUEs groups according to gender (P < 0.005), age (P < 0.001) and years of professional experience (P < 0.001).
As seen in this study, the most preferred digital imaging method was periapical radiography. However, 63.5% of the endodontists stated that DRI increased the number of exposures, which is in accordance with other recent reports. ,,,
Use of film holders is highly recommended, and the paralleling film-taking technique in endodontics is known to be superior to the bisecting angle technique. , However, patient's finger was still frequently used during film taking. The present study showed that 15.3% of the endodontists have used a film holder while taking digital images. This rate was lower than previous reports. ,
CBCT is a recent dental imaging modality, and compared to the patient radiation dose for maxillofacial imaging by CT (~2000 mSv), exposes the patient to 76.2% less radiation. ,,,,, Because of the field of view, the beam is limited to a smaller area, leading to a reduction in radiation dose. ,,,,,, Of the endodontists, 66.7% stated that they had previous knowledge of CBCT. A correlation between age/experience and awareness of CBCT was observed (P < 0.01). The percentage of endodontists knowledge regarding CBCT was lower (26.1%) in endodontists over 40 years of age when compared with younger age groups (P < 0.01) and type of practice (P < 0.01). No statistically significant difference was found between male and female endodontists. Of all endodontists, 62.2% were aware of the difference between CT and CBCT regarding the radiation dose and 41.9% stated that they had referred their patients for CBCT. The main reasons for CBCT referrals were similar to those provided by general dentists. ,
Although 56.8% of the endodontists indicated that they had controls of their X-ray units, 43.2% ignored the need for routine service. In a survey in 2005, Ilguy et al.,  reported that only 16.7% of Turkish general dental practitioners had their X-ray units serviced routinely. In a similar survey in 2011, 47% of the respondents reported that they have periodic maintenance of radiographic equipment which was comparable to the 56.8% of our survey. Owing to the fact that our survey was amongst Endodontic Speacialists, this increase in the percentage of practitioners having their X-ray units' controlled was not surprising. Maintenance of the radiographic equipment is important for radiation safety; however, some endodontists did not seem to be concerned about the need for radiation protection.
Scientific meetings and congresses held by dental associations and universities helped promote further education for the benefit of practitioners. Internet was also noted as another source used by endodontists to update their knowledge.
In conclusion, this study clearly showed that the number of endodontists using digital imaging and knowledge of CBCT have been increasing in Turkey. Continuing education in dentomaxillofacial radiology has an important role in the transfer from analog to digital radiology. The findings of the present study highlighted the need for adapting to new technologies via continuing education.
| Acknowledgment|| |
The authors would like to thank all colleagues participated in this study.
| References|| |
|1.||Miles DA, Razzano MR. The future of digital imaging in dentistry. Dent Clin North Am 2000;44:427-38. |
|2.||Wenzel A, Møystad A. Decision criteria and characteristics of Norwegian general dental practitioners selecting digital radiography. Dentomaxillofac Radiol 2001;30:197-202. |
|3.||Wenzel A, Møystad A. Experience of Norwegian general dental practitioners with solid state and storage phosphor detectors. Dentomaxillofac Radiol 2001;30:203-8. |
|4.||Berkhout WE, Sanderink GC, Van der Stelt PF. A comparison of digital and film radiography in Dutch dental practices assessed by questionnaire. Dentomaxillofac Radiol 2002;31:93-9. |
|5.||Brian JN, Williamson GF. Digital radiography in dentistry: A survey of Indiana dentists. Dentomaxillofac Radiol 2007;36:18-23. |
|6.||Dölekoðlu S, Fiºekçioðlu E, Ilgüy M, Ilgüy D. The usage of digital radiography and cone beam computed tomography among Turkish dentists. Dentomaxillofac Radiol 2011;40:379-84. |
|7.||Ilgüy D, Ilgüy M, Dinçer S, Bayirli G. Survey of dental radiological practice in Turkey. Dentomaxillofac Radiol 2005;34:222-7. |
|8.||Kamburoðlu K, Kurºun ª, Akarslan ZZ. Dental students' knowledge and attitudes towards cone beam computed tomography in Turkey. Dentomaxillofac Radiol 2011;40:439-43. |
|9.||European Society of Endodontology. Quality guidelines for endodontic treatment: Consensus report of the European Society of Endodontology. Int Endod J 2006;39:921-30. |
|10.||van der Stelt PF. Filmless imaging: The uses of digital radiography in dental practice. J Am Dent Assoc 2005;136:1379-87. |
|11.||Van der Stelt PF. Better imaging: The advantages of digital radiography. J Am Dent Assoc 2008;139:7-13S. |
|12.||Nair MK, Nair UP. Digital and advanced imaging in endodontics: A review. J Endod 2007;33:1-6. |
|13.||Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone beam computed tomography in endodontics. Int J Dent 2009;2009:634567. |
|14.||Kaptan RF, Haznedaroglu F, Kayahan MB, Basturk FB. An investigation of current endodontic practice in Turkey. ScientificWorldJournal 2012;2012:565413. |
|15.||Turkish Endodontic Society. Available from: http://www.turkendodontidernegi.org/2013 [Last accessed on 2013 Mar 03]. |
|16.||Jacobs R, Vanderstappen M, Bogaerts R, Gijbels F. Attitude of the Belgian dentist population towards radiation protection. Dentomaxillofac Radiol 2004;33:334-9. |
|17.||Davies C, Grange S, Trevor MM. Radiation protection practices and related continuing professional education in dental radiography: A survey of practitioners in the North-east of England. Radiography 2005;11:255-61. |
|18.||Aps JK. Flemish general dental practitioners' knowledge of dental radiology. Dentomaxillofac Radiol 2010;39:113-8. |
|19.||Berkhout WE, Sanderink GC, Van der Stelt PF. Does digital radiography increase the number of intraoral radiographs? A questionnaire study of Dutch dental practices. Dentomaxillofac Radiol 2003;32:124-7. |
|20.||Gound TG, DuBois L, Biggs SG. Factors that affect the rate of retakes for endodontic treatment radiographs. Oral Surg Oral Med Oral Pathol 1994;77:514-8. |
|21.||Peciuliene V, Rimkuviene J, Maneliene R, Drukteinis S. Use of dental radiography among Lithuanian general dentists. Stomatologija 2009;11:77-82. |
|22.||Chandler NP, Koshy S. Radiographic practices of dentists undertaking endodontics in New Zealand. Dentomaxillofac Radiol 2002;31:317-21. |
|23.||Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. Endodontic applications of cone-beam volumetric tomography. J Endod 2007;33:1121-32. |
|24.||Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4-and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 2004;33:83-6. |
|25.||Arnheiter C, Scarfe WC, Farman AG. Trends in maxillofacial cone-beam computed tomography usage. Oral Radiol 2006;22:80-5. |
|26.||Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl HG. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:114-9. |
|27.||Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin North Am 2008;52:707-30. |
|28.||Chau AC, Fung K. Comparison of radiation dose for implant imaging using conventional spiral tomography, computed tomography, and cone-beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:559-65. |
[Table 1], [Table 2], [Table 3], [Table 4]