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Introduction
Literature has
shown that endodontic
treatment is rendered most commonly following microbial
aggression to the dental pulp [1].
Recently, there has been increase in overall endodontic treatments across the
world due to more patient awareness and desire to save the natural teeth. The
study of endodontic epidemiology may help prediction of future needs for dental
treatment in a growing dentate population since the endodontic status of a
tooth is important for its survival. It may also be a useful tool in the
evaluation and planning of dental education in a particular country. There are
many epidemiological studies which have reported prevalence of endodontically
treated teeth in respective populations by evaluating either the total number
of treated teeth or the number of individuals with endodontic treatment [2-17].These
studies showed that 2.3% to 21.4% of all teeth had endodontic treatment and the
variation is seen along with the geographic variation of population (Table 1).
To our knowledge,
the prevalence of endodontically treated teeth in the Malaysian population has
never been investigated. The estimates on their prevalence have mainly been
based on studies from other countries. Hence, the purpose of this study was to
use radiographic examination to investigate the prevalence of endodontic
treatment in an adult Malaysian population with respect to age, sex, ethnicity
and type of tooth.
Materials and Methods
The sample of
this cross-sectional study examined the records of total 1663 patients visiting
the dental clinics of an AIMST University in Kedah state of Malaysia from
July 2015 to November 2020. The patients belonged to all the states of Malaysia
and satisfied the inclusion criteria which were as follows, irrespective of sex
and ethnicity: Malaysian nationality, age group 18 to 75 years, visited the
dental clinic in last 5 years, minimum 7 teeth present. Orthopantograms
(Cranex 3d, Kavo), were retrieved from records of patients. Any radiographic
evidence of presence of radio-opaque material such as root canal filling
material, endodontic post or restorative
material in pulp chamber was considered as Endodontic
Treatment or Therapy (ET) of the tooth [9]. Teeth were excluded whenever it was
not possible to differentiate from a restoration of intact tooth without any
pulpal involvement. Third molars, supernumerary teeth and faulty radiographs
were also excluded.
Four independent dental
professionals were designated for observation and
recording the data under supervision of an experienced endodontist. The
interpretation criteria were discussed while examining the radiographs. First
150 radiographs were initially examined by the observers for calibration and
standardization of evaluation criteria. When a consensus was not reached after
the four observers examined the radiographs, the endodontic specialist made the
final decision. The interpretation of radiographs in terms of tooth showing the
evidence of endodontic treatment or therapy was recorded as data along with the
age, sex, ethnicity of the patients and the type of tooth. From 1663 records, a
total of 33462 teeth were examined with mean 20.12 teeth per patient. A total
of 16061 teeth were examined from male patients while 17401 teeth were examined
from female patients (Table 2).
Among the age groups, 6960 teeth were examined for patients less than 30 years
of age and 4620 teeth were examined for patients above 60 years of age. Age
group 31 to 40 years had maximum number of teeth examined being 11645 (Table 3).
Table1:Results from various studies conducted for general population of different geographic areas.
Table2: Prevalence of endodontic treatment according to gender.
Malay, Chinese
and Indian population had 11727, 10930 and 9543 teeth examined respectively
according to ethnic groups (Table 4).
Upper left canines were the most examined teeth for the tooth-wise category
while lower left first molar were least in number to be examined when compared
to other teeth (Table 5). Data was
analysed statistically using Odds ratio, logistic regression and chi-square
test. Significance level was set at p<0.05. Interobserver agreement was
assessed using kappa (k) values.
Results
Out of 33462
included teeth, 7856 (23.48 %) teeth showed evidence of endodontic therapy.
Table 2 to table 5 shows the prevalence of the distribution of endodontically
treated teeth according to gender, age groups, ethnicity and tooth type
respectively. There was a significant difference among the various groups.
Females (60.5%, p<0.001) showed the greater prevalence than males (Table 2).
The largest number of endodontic cases were found among individuals aged 31 to
40 years (35.2%, P<0.001) (Table 3). Malay population had higher prevalence
of overall ET teeth, while Indian population showed highest percentage of ET
teeth within any ethnic group (Table 4). Maxillary molars
and mandibular molars were the teeth in which endodontic
treatment was most frequent, whereas canines showed the lowest prevalence
(Table 5).These findings were in similar fashion among most of inter groups and
intra groups comparison, i.e. compared to males, the females had higher
prevalence of ET teeth from all ET teeth examined (27.31%) in both groups as
well as all teeth examined in female group (60.5%). Interobserver agreement was
excellent, since kappa values were greater than 0.9.
Discussion
This study
evaluated the prevalence of endodontically treated teeth in Malaysian
sub-population with respect to sex, age, ethnicity and tooth type since no such
study has been done earlier for this sub-continent. This methodology of this
study was designed similar to many previous studies by examining radiographic
images of a random sample from a database to calculate the number of endodontically
treated teeth [6,7,9,18]. The inclusion criteria for
cases stated the adult patients of age groups from 18 years to 75 years so that
maximum number of permanent teeth could be included. The upper age limit also
enabled to satisfy other inclusion criteria, minimum number of teeth present to
be 7; which is one fourth of maximum 28 teeth
evaluated in a
patient. This was to avoid any false higher number of the endodontically
treated teeth per non treated teeth and to get the sample size with minimum
error [18]. Evaluation of an orthopantograms (OPGs) was used to collect data
since these have been used very often used for such purpose in epidemiological
studies [7,18]. An OPG is an effective and more advantageous method to record
the large volume of patient data in university dental clinics where full-mouth
periapical radiographs are not used routinely [11,19]. It conveniently allows a
quick examination of all teeth using only one radiograph, thereby a lower
patient radiation dose. The ethical concept of this study did not involve any
further exposure of the patient to radiation; hence no new radiographs were
taken.
We examined a
large number of patients’ records to collect a significant data that could get
results closer to that truly exists. This was the main challenge faced during
the study taking few years. A total of 33462 teeth from 1663 patient records
were examined after excluding the cases which did not satisfy inclusion
criteria. The mean number of remaining teeth per patient in this study was
20.1, which is lower than other reported in other studies [8,20,21]. This might
be the reason for a higher overall percentage since lesser teeth were present
per patient. Patients having seven or more teeth were counted so that teeth in
function could be included and to rule out cases where teeth might have been
removed following a severe
periodontal disease. Had those teeth been counted, it would
have resulted in far higher number of ET teeth. This studied showed that 22.81
% of examined teeth were endodontically treated, which is higher than any other
population including European and American. Table 4 shows the results of the
similar studies done in general populations of adult age groups from other
geographic locations. Another study which revealed higher prevalence of
endodontic treatment (20.5%) was done by Tsuneishi et al [9] for Japanese adult
population. However, they used full-mouth intraoral radiographs instead of OPG
which might be a factor of higher results [3,8].
The results from
this study can be correlated to other studies in few areas. The percentage of root filled teeth was
highest when compared to other populations but can be compared to those
obtained from French and Brazilian studies [9,12] (Table 1). The high results
of this study could also be related to the fact that a larger proportion of the
patients attending dental school might be from lower socio-economic status
having poorer oral health and available during operating dental school hours
[22]. Lack of referral to specialist might have led to extraction as the
treatment of choice rather than root canal
therapy for difficult cases; but this fact should not have
any overall effect on percentage of ET since the extracted teeth will reduce
the total number of teeth examined.
The results of
this study showed that females had higher prevalence of ET cases as compared to
males (P<0.01); however, the number of teeth evaluated were also more in
females. The significant difference definitely suggests that females have more tendencies
to undergo treatment and save the teeth, but it also might indicate that more
females attended the dental clinic and
additionally females have less missing teeth. These results were in agreement
with previous studies [10,23], however some studies had showed that gender had
no effect on frequency of ET [6,19,21]. These results are consistent with many other
studies done across the globe in which males had significantly fewer remaining
natural teeth than females and hence average number of root-filled teeth was
also lower among males [6,7].
Among the age
groups, 31 to 40 showed significantly highest prevalent ET cases while 51 to 60
years showed least (P<0.05). A study done in year 2015 for Nigerian
subpopulation also revealed that younger age group patients had higher
prevalence [16].The highest ET cases in the age group 31 to 40 can be related
to the fact that it had highest number of teeth examined and other factors like
higher cariogenic potential due to modern dietary habits and better awareness
for saving teeth rather than choosing the extraction as treatment option. Also,
younger patients have easier root canal morphology, thereby making endodontic
therapy treatment of choice. This was in contradiction of findings from other
studies which emphasised that younger people tend to visit the dentist more
often when compared to elderly and thus they have a lower incidence of caries
and periodontal diseases (14). However, in future studies this age group might
present with higher prevalence due to increased awareness and dynamic nature of
this disease prevalence [24].
Age group 51 to
60 years had lower prevalence, mainly due to lesser number of teeth present in
this age group and treatment plan modification due to age needs. This was in
contrary of the findings from other studies which showed the frequencies of
endodontic treatment increased with age [6,12,19]. However it had the highest
percentage of ET within any group, i.e. percentage of ET found in particular
group to overall teeth examined in that group was 28.1, highest when compared
to others (intra group comparison), this might be due to fact that increase may
be a cumulative effect resulting from longer exposure to function, caries, and
subsequent operative procedures [2]. On percentage basis, 41 to 50 year group
had lowest which may be due to higher number of teeth retained in this group
while lesser incidence of caries leading to root canal.
This
subpopulation consists of 3 major ethnic groups, namely Malays, Chinese and
Indians in decreasing order of proportion [25]. However, these proportions may
differ geographically within Malaysia. The findings of ET teeth were most
evident in Malay population owing to the highest number of teeth evaluated in
this group. Among these groups, following sequence was observed from highest to
lowest on percentage basis: Indians, Malays, Chinese, others. Although Indian
ethnic group constitutes to least to Malaysian population from three major
ethnic groups, still the prevalence of ET teeth was highest for this group
(P<0.05). This result can be multifactorial including the socio-economic
aspects and further cross-sectional studies must be done to support these
findings. Least prevalence was seen in other group which constitutes very minor
portion of the population [9].
Among the teeth
examined, it was observed that molars had highest prevalence, followed by
premolars, incisors and least in canines (P<0.05). Findings were more
significantly higher for maxillary teeth than mandibular teeth and higher for
left side than right side. There was no significant difference between first
and second molars. These findings can be related to both patient and tooth
factors. A better care is expected for lower and anterior teeth by the
patients, thereby reducing any chance of decay and subsequent treatment. At the
same time, patients may have fewer posterior teeth remaining due to choice of
treatment being extraction rather than endodontic
treatment.
This can be due
to lack of access to specialist referral for difficult posterior endodontic
cases, thereby choosing extraction. Kirkevang et al [6] in 2001 found that
significantly more molars had been endodontically treated (8.1%) than premolars
(5.4%) or anterior teeth (2.5%). Another recent studies of French and Sudanese
population demonstrated that molars had higher prevalence than anteriors or
premolars as endodontically treated teeth [7,26]. Other previous studies also
have reported that maxillary teeth were significantly more root filled teeth
(62.3%) than in the mandible (37.7%) [11,23,27].
Conclusion
The prevalence of
endodontically treated teeth evaluated in the present study was 23.48% for a
Malaysian adult population within age group of 18 to 75 years having minimum 7
teeth per individual. The prevalence is higher than that observed in
epidemiological studies conducted in other countries. Endodontic treatment was
most frequent in females, 31 to 40 year-olds and Indian ethnic group. First
molars were most commonly treated teeth (20.25%) while canines were the least
(6.06%). A higher percentage of the ET teeth suggest the strongly adverse
impact of dental caries. This number might is considered high even when the
concept of preserving natural teeth is still emerging to the sub- population
involved in this study compared to other countries or communities. Although the
data was collected from records of individuals visiting the dental clinic
situated in Kedah state of northern Malaysia, a portion of them belonged to
other states too. At any time in future, the prevalence of endodontic treatment
will be definitely higher due to increased awareness, unless it will
counter-balanced by lesser incidence of dental caries and its sequelae. These
results also indicate the necessity of more educational programs and advanced
training of a greater number of general dentists in Endodontics. Definitely,
the access to dental care and
awareness which is be different in other parts of Malaysia, would affect the
prevalence; hence this population may not be representative for whole of
country and additional studies may be required to investigate further for other
sub-populations.
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Corresponding author
Rahul Rathi, Senior Lecturer,
Faculty of Dentistry, AIMST University, Kedah 08100 Malaysia, E-mail: drrahulrathi@aimst.edu.my
Citation
Rathi R, Saroha P, Ling TS, Lim
SK and Lim RY. Prevalence of endodontically treated teeth in an adult Malaysian
population attending a dental school clinic (2021) Dental Res Manag 5: 12-16.
Keywords
Age, Endodontic, Ethnicity, Gender, Malaysia,
Prevalence, Tooth, Treatment
