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European Journal of Dental Education ISSN 1396-5883
Students’ perceptions of pre-clinical endodontic training with
artificial teeth compared to extracted human teeth
D. I. Al-Sudani and S. O. Basudan
Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
keywords Abstract
dental education; endodontics; artificial teeth;
extracted teeth; pre-clinical teaching. Purpose: Artificial teeth have several advantages in pre-clinical endodontics training.
This study aimed to compare artificial resin teeth with extracted human teeth, from a
Correspondence student’s perspective, during a pre-clinical undergraduate endodontic course for three
Dina. I. Al-Sudani consecutive academic years (2011—2014).
Department of Restorative Dental Sciences
College of Dentistry
Methods: At the end of the course, students completed a questionnaire that included
King Saud University
questions about their perceptions of the difficulty of artificial teeth vs. natural teeth
P.O. Box 60169
and ranked the perceived advantages of artificial teeth.
Riyadh 11545, Saudi Arabia
Tel: +96611 467 7420
Fax: +96611 467 9016 Results: Participants expressed that all procedures, except obturation, were more diffi-
e-mail: [email protected] cult to perform on artificial teeth than on natural teeth, a result that was due to the
hardness of the resin. They ranked the fairness and availability as the best advantages.
Accepted: 9 June 2016
doi: 10.1111/eje.12223 Conclusion: Artificial teeth have multiple advantages but cannot replace natural teeth.
The physical characteristics through the manufacturing material of artificial teeth
should be enhanced to increase wider use and acceptance.
For many years, extracted teeth were used almost exclusively
Introduction
during teaching endodontic curricula. However, the use of
In dental education, there is a need for extensive, hands-on extracted teeth has some drawbacks, such as the possibility of
pre-clinical training before patient’s treatment is carried out cross-infection, unavailability of these teeth and anatomical
for the first time (1). Throughout the years, numerous tech- variability of extracted teeth, which may not allow for a valid
niques have been devised to teach students to perform root assessment of a student’s individual performance. Another
canal treatment. Replicas of actual teeth have been produced major organisational problem is that extracted human teeth are
with transparent resins in which the pulp chamber and root potentially infectious (7).
canals have been demarcated with coloured resin (2). Other Currently, artificial teeth models have been made of opaque
techniques have involved the decalcification and clearing of resin to reproduce the features of natural teeth for teaching
human teeth to allow for direct visualisation of the root canal various root canal treatment techniques. Artificial teeth do not
anatomy and direct observation of the root canal preparation, have a risk of infection, are available in large numbers, allow
whereby one wall of an extracted tooth is removed to the for a validated assessment through their uniformity, offer dif-
level of the pulp chamber and root canal (3). Blocks with ferent anatomical challenges and can be created as 3D-printed
simulated canals have been prepared in which both straight- training replicas, allowing students to learn to perform stan-
ened and curved canals could be produced in artificial resin dardised procedures. They also allow students to practice the
for direct visualisation of instrumentation (4). Likewise, the same procedure until they obtain consistently good results with
use of extracted teeth is one of the most popular techniques a given technique for a given anatomical challenge (2, 7).
used during pre-clinical endodontic training. Each of the In the last few years, different models have been introduced
above techniques has its advantages and disadvantages. To in the market for endodontic training, such as models pro-
date, it is common practice to use a combination of artificial duced by Acadental (Acadental, Overland Park, KS, USA) and
root canal models and extracted human teeth during pre- Smile Factory (Fabrica de Sorrisos, Aruja, S~ao Paulo, Brazil).
clinical training (1, 5, 6). These models offer numerous advantages and a favourable
e72 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Eur J Dent Educ 21 (2017) e72–e75
16000579, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eje.12223 by Karabuk Universitesi, Wiley Online Library on [29/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Al-Sudani & Basudan Artificial vs. natural teeth in endodontic teaching
potential in endodontic pre-clinical training as well as research anonymous and confidential. Multiple-choice questions (with
(8). ModuPRO EndoTM and Real Endo-T teeth are widespread open response) assessed the exertion of treating artificial teeth
in endodontic training (Acadental) and have been promoted as during various steps of root canal treatment compared to natu-
a promising entity for pre-clinical endodontic training using ral teeth. A final question asked the participants to rank the
both the jaw model and artificial teeth. The model has mod- perceived advantages of artificial teeth (see attached question-
ules/sextants onto which typodont teeth with simulated root naire). Data were analysed quantitatively using the statistical
canals can be mounted with a mounting media. The modules Package for Social Science 19 (IBM SPSS Statistics, IBM
have magnetic strips on the base that can be attached to a car- Company, Armonk, NY, USA).
rier tray. This model has the advantage of simulating the clini-
cal situation using the typodont and artificial teeth. It also
Results
offers different anatomical challenges and 3D-printed training
replicas, and procedural standardisation. Another feature of this Of 121 students who were invited to participate, 102
model is the possibility of using an electronic apex locator responded; the response rate was 84.3%. Forty per cent of the
whilst training on the typodont teeth. participants were from the academic year 2011/2012, 23.0%
To date, there is insufficient data to determine whether a from 2012/2013 and 37.0% from 2013/2014. The mean age of
model with artificial teeth is a suitable substitute for extracted the participants was 21.08 years (SD 0.42). All participants
human teeth. Therefore, the purpose of this study was to com- were female. Figure 1 summarises the students’ responses to
pare artificial resin teeth with extracted human teeth, from a different steps of root canal treatment. Overall, all procedures,
student’s perspective, during the pre-clinical endodontic course except obturation, were expressed to be more difficult to per-
for academic years 2011—2014 at King Saud University. form on artificial rather than natural teeth.
Most students (59%) reported that performing an access cav-
ity procedure on artificial teeth was more difficult than on nat-
Materials and methods
ural teeth. The most common reasons as listed by the students
The study design was approved by the College of Dentistry’s in the open textbox were no replication of natural tooth ‘drop’
research centre and its ethical committee (FR 0285) at King to the pulp chamber, inability to differentiate between enamel
Saud University. A questionnaire was formulated to evaluate and dentin layers, poor visibility, dark chamber, bur slipping
the students’ perception on artificial teeth that were manufac- easily on the outer surface and an increased risk of procedural
tured for endodontics (Real-T Endo, Acadental). The question- errors. Difficulties locating the pulp chamber and orifices were
naire was distributed from 2011 to 2014, over three academic reported by 51% of the students. The reasons were as follows:
years. The study targeted undergraduate students at the end of poor visibility of orifices and darkness of the chamber, obstruc-
an undergraduate pre-clinical endodontic course who had per- tions of the pulp by the sticky material in the pulp and absence
formed root canal treatment on at least four artificial teeth of anatomic guidelines.
(two anteriors and two molars) and five extracted human teeth Sixty-four per cent of the students reported instrumentation
(one anterior, two pre-molars and two molars) throughout one as the most difficult step during the treatment of artificial teeth.
academic year. A total of 121 participants were asked to com- They explained that blockage and debris were frequent. In
plete a questionnaire that included questions on their observa- addition to general mishaps and, more specifically, perforations
tion, comparing the perception of difficulty of artificial and due to the loss of tactile sensation because of the ‘soft dentin’,
natural teeth, as well as on their ranks of the perceived advan- 60% also reported that irrigation was difficult. Approximately
tages of artificial teeth. Participation in the survey was optional, 15% reported that the resilience (hardness) of the artificial
Fig. 1. Comparison of difficulty for different stages of root canal treatment on artificial vs. natural teeth.
ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd e73
Eur J Dent Educ 21 (2017) e72–e75
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Artificial vs. natural teeth in endodontic teaching Al-Sudani & Basudan
teeth was 75—100% of the natural teeth. One-half (51%) availability. There are different types of Acadental’s Real Endo-
reported the resilience as 50% to <75%, and 34% reported it as T teeth. Crowns are made of opaque resin, whilst the roots are
<50%. Sixty-three per cent reported that the hardness made made of transparent resin, allowing for the direct visualisation
instrumentation more difficult. Most reported that obturation of procedural steps and a better understanding of endodontic
was similar for artificial and natural teeth, and only 26% concepts. Meanwhile, students enthusiastically accepted the
reported that obturation was more difficult. Difficulties were concept of using artificial teeth in their pre-clinical endodontic
mainly due to struggling with the instrumentation and achiev- curricula.
ing adequately tapered canals, voids, blockage and separation of At the end of the course, students reported their opinions.
the crown when hot instruments were used. Sixty-eight per cent rated that artificial teeth were inferior to
Despite the difficulties with artificial teeth, they have several natural teeth during access preparation, increasing the risk of
advantages. The students ranked fairness in terms of difficulty, procedural errors due to several reasons at the different stages
availability, standardisation in understanding the basic anatomy of access cavity. These reasons include the glassy surface, caus-
and sanitation as the most important features of artificial teeth. ing the bur to slip easily on the outer surface; the inability to
Twenty-eight of the respondents incorrectly answered this ques- differentiate between the enamel and dentin layers; and the
tion by not ranking the items, such as checking a single item inability to locate the pulp chamber and orifices due to poor
only; as a result, those answers were excluded. visibility, darkness of the pulp chamber, obstruction of the
pulp chamber by the wax material and absence of anatomic
guidelines. As some students have stated: ‘I can’t see clearly,
Discussion
it’s too dark, orifices are not clear, I can’t feel errors if I make
Education using pre-clinical endodontic training is an integral one’, ‘There is no difference between enamel and dentin, and
part of the dental curriculum to ensure that students have you can’t feel the drop’. One student explained further: ‘The
competence prior to clinical training. Most universities still use material duplicating dentin was very soft, so the bur would
a combination of artificial blocks and extracted human teeth drop before reaching the pulp chamber’. Moreover, ‘The
for pre-clinical training (6). Both extracted human teeth and acrylic keeps blocking the vision and cannot be removed like
artificial blocks have some limitations in endodontic training. the natural tooth easily, even using the air/water syringe’. Gen-
Nassri et al. (2) introduced complete artificial resin teeth with erally, ‘Drilling in plastic is more difficult than in natural
multiple roots and root canals, and they reported their accep- teeth, also locating the canals is easier in natural [teeth]
tance amongst professors of endodontics. This opinion of because of the shape of the floor’. This finding corroborates
experts can differ from that of students, the main benefactor the results of a previous study that reported the need for
in endodontic education. Moreover, Tchorz et al. (7) reported improvements in the content of the pulp chamber and root
that the application of artificial teeth instead of extracted canals of resin teeth (9).
human teeth did not have an effect on the technical quality of Sixty-four per cent of the students reported difficulty in
root fillings in terms of the position in relation to the root instrumentation due to the loss of tactile sensation, which
apex or creation of aberrations. However, the efficiency of arti- increased the risk of procedural errors. ‘Blockage’ and ‘debris’
ficial teeth compared to extracted human teeth during pre- that are ‘sticky’ were mentioned over 30 times. In the words of
clinical endodontic education has not previously been investi- a student: ‘There is more chance of errors, less tactile sensa-
gated. tion, and plugging of debris and wax’. Perforations were the
Our students have often complained about the increasing most common error reported. In addition, there was a ten-
difficulty of obtaining natural teeth as well as the anatomical dency of canal blockage as a result of the debris, which was
variability and difficulty of treating extracted teeth, which does gluey in nature; this result was consistent with the study by
not allow for a valid assessment of their individual perfor- Luz et al., (9) who related this debris to the different viscosities
mance. This was in agreement with previous studies that noted of the content of the pulp chamber compared to pulpal tissue,
the shortcomings of natural extracted teeth during endodontic which makes it more difficult to remove. Most of these com-
training (7, 9). In our endodontic pre-clinical course for three plications can be associated with the materials that are used in
academic years, 2011—2014, the courses were modified to the manufacturing of these teeth; the majority of the partici-
combine artificial root canal models and extracted human teeth pants reported that the artificial teeth were less resilient than
for endodontic pre-clinical practice. The idea of including arti- the natural teeth; this observation was in accordance with a
ficial root canal models was to overcome the limitations of study by Nassri et al. (2), who examined another artificial teeth
natural teeth, especially the unavailability of these teeth and model and reported that endodontists favourably accepted the
how time consuming it is to prepare them, which includes teeth model, except for the texture and hardness of the root
examination, case selection, faculty approval and sterilisation, canal. In the study by Luz et al. (9), students reported that
before they can be mounted in the dentoform. The findings of artificial teeth were inferior to resin blocks with respect to the
Tchorz et al., (7) support the inclusion of an artificial tooth hardness of the material. This directly affected instrumentation
model. They reported that there was no significant difference of the canal and reaching the required shape and size, or as
in the clinical quality of root canal treatment performed by students explained ‘It’s difficult to reach a good taper’ which
students who trained on artificial vs. natural teeth in their pre- may make obturation more difficult. However, the obturation
clinical endodontic course. The Acadental tooth model was procedure itself was perceived as mostly similar to it in natural
integrated into the course. This model was chosen because of teeth. Proving that manufacturing material of the plastic teeth
their wide use in the dental board examination and their was the major hindrance.
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Eur J Dent Educ 21 (2017) e72–e75
16000579, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/eje.12223 by Karabuk Universitesi, Wiley Online Library on [29/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Al-Sudani & Basudan Artificial vs. natural teeth in endodontic teaching
The result of the present study is in agreement with other
studies that used different models of artificial teeth (2, 7).
Appendix 1: The Questionnaire
Accordingly, artificial teeth cannot replace the requirement to Please choose one ‘best’ option unless otherwise indicated:
learn with natural teeth as part of endodontic training curric- 1 Performing the access on the acrylic teeth compared to the
ula. However, considering the advantages of artificial teeth, they natural teeth was:
could be incorporated with natural teeth, especially due to their □ Much easier
availability and standardisation. Furthermore, their physical □ Same as natural
characteristics through the manufacturing material should be □ More difficult
enhanced to promote their wider use and acceptance. This (Mention why): _________________
study tested one brand of artificial teeth, whilst other brands 2 Locating the pulp chamber and canal orifice(s) compared to
may be perceived differently. In addition, our sample consisted the natural teeth was:
of undergraduate students only, the main target in education, □ Much easier
whose perceptions can differ from experts. □ Same as natural
□ More difficult
(Mention why): _________________
Conclusion
3 Canal instrumentation on the plastic teeth compared to the
Based on the results of the present study, students perceived natural teeth was:
artificial teeth as unsatisfactory because of the physical charac- □ Much easier
teristics of these teeth, making them more difficult to treat □ Same as natural
compared to natural teeth. Despite the reported difficulties, the □ More difficult
participants recognised the advantages of artificial teeth, but (Mention why): _________________
they suggested that improvements in the physical characteris- 4 In your opinion, the resilience (hardness) of the plastic teeth
tics, especially hardness of resin teeth, are needed so that they resembles that of the natural teeth by:
more closely resemble natural tissues (enamel & dentin). □ 75—100%
□ 50 to <75%
□ <50%
References
5 In your opinion, the resilience (hardness) of the acrylic teeth
1 Qualtrough AJ, Whitworth JM, Dummer PM. Preclinical leads to:
endodontology: an international comparison. Int Endod J 1999: 32: □ Easier instrumentation
406–414. □ Difficult instrumentation
2 Nassri MR, Carlik J, da Silva CR, Okagawa RE, Lin S. Critical □ Has no effect on instrumentation
analysis of artificial teeth for endodontic teaching. J Appl Oral Sci 6 Obturation of plastic teeth compared to natural teeth was:
2008: 16: 43–49.
□ Much easier
3 Hasselgren G, Tronstad L. The use of transparent teeth in the
teaching of preclinical endodontics. J Endod 1975: 1: 278–280.
□ Same as natural
4 Dummer PM, Alodeh MH, Al-Omari MA. A method for the □ More difficult
construction of simulated root canals in clear resin blocks. Int (Mention why): _________________
Endod J 1991: 24: 63–66. 7 Irrigation of the canals from debris was:
5 Dummer PM. Comparison of undergraduate endodontic teaching □ Much easier
programmes in the United Kingdom and in some dental schools in □ Same as natural
Europe and the United States. Int Endod J 1991: 24: 169–177. □ More difficult
6 Sonntag D, Barwald R, Hulsmann M, Stachniss V. Pre-clinical 8 The following are advantages of the plastic teeth over
endodontics: a survey amongst German dental schools. Int Endod J natural:
2008: 41: 863–868.
Please rank the following advantages from 1 to 5 according to
7 Tchorz JP, Brandl M, Ganter PA, et al. Pre-clinical endodontic
training with artificial instead of extracted human teeth: does the
their importance (1 = Most important advantage. . .6 = Least
type of exercise have an influence on clinical endodontic outcomes? important).
Int Endod J 2015: 48: 888–893. □ ___ Availability
8 AlShwaimi E, Narayanaraopeta U. Effect of time on electronic □ ___ Easier to perform all aspects of root canal treatment
working length determination with a novel endodontic module in □ ___ They are less fragile than natural teeth
preclinical endodontic training. Saudi J Med Med Sci 2014: 2: 37. □ ___ Their standardization helps in understanding of
9 dos S Luz D, de S Ourique F, Scarparo RK, et al. Preparation time basic anatomy
and perceptions of Brazilian specialists and dental students regarding □ ___ Fairness in case difficulty
simulated root canals for endodontic teaching: a preliminary study. J □ ___ More hygienic than natural teeth
Dent Educ 2015: 79: 56–63.
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