Challenges faced by undergraduate dental students during root canal treatment: a survey study

Introduction: root canal treatment is a challenging procedure often first encountered by undergraduate dental students, leading to various difficulties and mistakes. Objective: this study aimed to identify the specific difficulties encountered by undergraduate dental students during root canal treatment and the frequency of mistakes they committed in relation to these difficulties.


INTRODUCTION
Root canal treatment is a complex and technically demanding procedure that requires a combination of theoretical knowledge and technical skills.The procedure can be challenging even for experienced dental professionals, and mistakes made during the procedure can result in a variety of complications 1,2 .Undergraduate dental students need to be equipped with the necessary knowledge and skills to perform root canal treatments effectively.However, the process of learning endodontic procedures can be a challenging experience for many students.Root canal treatment requires a high level of precision, and even minor errors can lead to significant problems.
Several studies have examined the difficulties encountered by undergraduate dental students during root canal treatment [3][4][5][6] .The challenges identified in these studies include difficulties in diagnosing endodontic conditions accurately, pain management during the procedure, placement of rubber dam, locating canal orifices, and working length determination, among others.These challenges highlight the importance of providing students with adequate training and education in root canal treatment to prepare them for their future professional careers.
Moreover, mistakes made by undergraduate dental students during root canal treatment can have significant implications for the patient's oral health 3,6 .The consequences of these mistakes can range from mild discomfort to severe pain and infection, and may require further interventions to correct 7 .Therefore, it is essential to identify the specific areas where students encounter difficulties and mistakes during root canal treatment to develop effective training programs and improve the quality of dental care.
The purpose of this study is to identify the specific difficulties encountered by undergraduate dental students during root canal treatment and to determine the frequency of mistakes made by students in various aspects of the procedure.The results of this study can provide valuable insights into the challenges faced by students during endodontic procedures, which can help educators develop more effective training programs and improve the quality of care provided to patients.

MATERIAL AND METHOD
This study employed a cross-sectional survey design to explore the difficulties encountered by undergraduate dental students during root canal treatment.The entire cohort of 60 third-year students, all at the same level of their dental education, was actively recruited to participate in this study.Data were collected using a self-administered questionnaire consisting of two parts.Part 1 contained 27 questions addressing various aspects of endodontic treatment, while Part 2 assessed the frequency of mistakes made by students in 11 key areas of root canal procedures.The questionnaire was designed based on a review of the literature and was pretested among a group of dental students to ensure its validity and reliability.
The response options for each question were based on a 4-point Likert scale: Never (0), Rare (1), Sometimes (2), and Frequent (3).This scale allowed the students to rate the frequency of their difficulties in each area, providing a nuanced understanding of their experiences (Appendix 1).The survey was administered either online or on paper, depending on the participants' preferences, and was completed anonymously to ensure the confidentiality of the responses.Data analysis was performed using Python programming language (Python 3.11) and the pandas, seaborn, and matplotlib libraries.The data was first prepared and cleaned to ensure accurate and consistent results.Data visualization by means of heatmaps was also used to better understand the distribution of the data.Heatmaps were created using the seaborn library (Appendix 2).Each heatmap was customized to highlight the mean values of each difficulty faced by dental students in root canal treatment, with the highest mean values shown in red and the lowest mean values shown in blue.The code used to create the heatmap and the customization options applied are provided in the Supplementary Material.
Ethical approval for the study was obtained from the institutional review board of Oman Dental College where the study was conducted, and all participants provided informed consent before participating in the study.

RESULT
Among the 60 participants in this study, 90% (54) were local students and 10% (6) were international students.All participants were female, with ages ranging from 21 to 24 years.The average age was 21.5 years, and the median age was 21 years.Heatmaps provided a clear and concise visual representation of the data, allowing for a better understanding of the challenges faced by dental students during root canal treatment.
The results indicate that the students encountered the most challenges in feeling the apical constriction/developing tactile sensation (mean: 2.40, median: 3), followed by difficulty with accessory cone placement (mean: 2.50, median: 3) and reaching the apex following canal location (mean: 2.16, median: 2).These findings suggest that students may struggle with fine motor skills and spatial awareness, which are essential for successful root canal treatments.Emphasizing the importance of a steady hand, spatial perception, and providing ample opportunities for practice with feedback could enhance students' skills in these areas.
On the other hand, students experienced the least difficulty with separation of instruments (mean: 0.944, median: 1) and sodium hypochlorite spills/accidents (mean: 1.13, median: 1).These results indicate that students may have a better understanding of instrument handling and safety precautions during root canal treatment.Dental educators should continue to emphasize the importance of proper instrument use and safety measures.
Overall, the variability in responses was moderate, with standard deviations ranging from 0.468 to 0.952.This variability may reflect individual differences in students' learning experiences, aptitude, or comfort with various aspects of root canal treatment.To ensure comprehensive and effective education, dental schools should consider incorporating a variety of teaching methods and resources, including hands-on practice, demonstrations, and theoretical coursework.Additionally, providing targeted support and resources for struggling students can help address individual difficulties and foster skill development.
These findings suggest that dental educators may need to focus on improving students' tactile skills, accessory cone placement techniques, and methods to accurately reach the apex during canal location to enhance the effectiveness of root canal treatment education.By addressing these specific challenges, dental schools can better prepare students for successful careers in dentistry (Figure 1). Figure 2 presents the frequency of mistakes in key aspects of root canal procedures reported by undergraduate dental students.The mean values range from 1.87 to 2.37 with a median of 2 for all questions except for question 8 which had a median of 2. The standard deviation values ranged from 0.456 to 0.675, indicating that the responses were relatively consistent for most questions.Students reported the highest frequency of mistakes in difficulty in reaching the apex (question 7) with a mean of 2.37 and locating canal orifices (question 5) with a mean of 2.26.The lowest frequency of mistakes was reported in rubber dam application (question 2 and 3) with a mean of 1.87 and 1.97 respectively, indicating that students had relatively good skills in this aspect of root canal treatment.

DISCUSSION
This study aimed to identify the specific difficulties undergraduate dental students encounter during root canal treatment.The results provide valuable insights into the areas where students face the most challenges, as well as those in which they demonstrate a better understanding.In this discussion section, we will elaborate on the implications of these findings and provide recommendations for dental education to address the identified difficulties.
The most significant challenges reported by students were related to feeling the apical constriction/developing tactile sensation, accessory cone placement, and reaching the apex following canal location.These difficulties highlight the importance of fine motor skills and spatial awareness in performing successful root canal treatments 8 .To address these challenges, dental educators should consider incorporating teaching methods that specifically target the development of these skills 9 .For example, incorporating simulation-based training with haptic feedback could help students develop a better sense of touch and improve their spatial perception 10,11 .Additionally, providing ample opportunities for hands-on practice with real patients, under the supervision of experienced clinicians, may also enhance students' skills and confidence in these areas 12 .
The study also identified challenges in other areas, such as diagnosis, pain management, canal location, and working length determination, indicating a need for comprehensive training in diagnostic and procedural skills, as well as patient management strategies 13 .Dental educators could consider incorporating more interactive and problem-based learning approaches to help students develop the critical thinking and decision-making skills necessary for successful root canal treatment 14 .
In contrast, students reported the least difficulty with dealing with manual and/or rotary instruments and sodium hypochlorite solution.These findings suggest that students have a relatively better understanding of instrument handling and safety precautions during root canal treatment.It is essential for dental educators to continue emphasizing the importance of proper instrument use and safety measures to maintain and further improve these skills.This can be achieved through regular reinforcement of safety protocols during lectures, demonstrations, and practical sessions 15,16 .
When comparing the mean scores of related questions and aspects from both heatmaps (Figures 1 and 2), it is evident that the difficulties faced by undergraduate dental students remain relatively consistent.Pain management, rubber dam application, reaching the pulp chamber, and locating canal orifices appear to be common challenges across both sets of data.Most students experience these difficulties at least "sometimes" during their root canal treatments.It is interesting to note that while students reported committing mistakes in certain areas of root canal treatment, they did not perceive these areas as problematic.This could be due to the fact that the mistakes were made during their learning process, and the students may have already learned from these mistakes 17 .Additionally, it is possible that the students did not fully recognize the potential consequences of their mistakes, such as the negative impact on patient outcomes and the need for additional treatment or corrections 18 .Dental educators should help students understand the significance of these mistakes and how they can be prevented, emphasizing the importance of continuous learning and improvement.
The moderate variability in responses observed in this study may be attributed to individual differences in learning experiences, aptitude, or comfort with various aspects of root canal treatment.Dental educators should be aware of these individual differences and consider adopting a personalized approach to teaching, where possible.This may involve offering additional support or resources to struggling students, as well as using a variety of teaching methods to cater to different learning styles 19 .Moreover, it is crucial for dental schools to foster a supportive learning environment where students feel comfortable seeking help and discussing their difficulties.Encouraging peerassisted learning, mentorship programs, and open communication between students and faculty can help create a positive atmosphere that promotes skill development and continuous improvement 20 .
This study has several limitations that should be considered when interpreting the findings.First, the sample was comprised solely of female students, which may restrict the applicability of the results to male students or mixed-gender cohorts.Second, the majority of participants were local students, potentially underrepresenting the experiences of international students who may encounter unique challenges and provide distinct perspectives.Third, the study was conducted at a single institution, which might limit the generalizability of the findings to other institutions with varying teaching methods, resources, or student populations.Future research could expand on this work by exploring the challenges faced by dental students in different settings, using more objective measures of performance, and investigating the effectiveness of specific educational interventions in improving their root canal treatment skills.Longitudinal studies can contribute to understanding the persistence and development of these challenges throughout students' dental education and professional growth.
The results of this study underscore the importance of addressing the identified challenges through targeted training and support, ultimately enhancing the competence of dental students in endodontics and contributing to better patient outcomes.Dental educators, program administrators, and professional organizations should consider these findings when designing and implementing curricula and training programs to ensure the continued development of skilled and confident dental practitioners.To better address the challenges faced by students during root canal treatment, dental education institutions and instructors could revise and adapt their curricula and teaching methodologies.Emphasizing hands-on training, offering additional resources, and incorporating problem-based learning approaches can help students develop the necessary skills to overcome these difficulties.Regular evaluation and feedback can identify areas of improvement and ensure the development of competent practitioners.
By addressing these identified challenges and implementing targeted interventions, dental education institutions can better equip their students with the skills and knowledge required to provide high-quality root canal treatment, ultimately improving patient outcomes and satisfaction.As the demand for quality dental care continues to grow, it is important to ensure that dental students are adequately prepared to meet the needs of their patients.

CONCLUSION
The findings of this study provide valuable insights into the specific challenges faced by undergraduate dental students during root canal treatment.Dental educators should use this information to refine their teaching methods and develop targeted interventions to address the identified difficulties.By focusing on improving students' tactile skills, spatial awareness, and fine motor skills, dental schools can better prepare their students for successful careers in dentistry and ultimately contribute to improved patient outcomes.

Figure 1 .
Figure 1.Difficulties faced by dental students in root canal treatment: a heatmap analysis of mean, median, and standard deviation.IOPA: Intraoral periapical radiograph.

Figure 2 .
Figure 2. Frequency of mistakes in key aspects of root canal procedures:a heatmap analysis of mean, median, and standard deviation.