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Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 314

Address for correspondence:


Dr. Ruchika Roongta Nawal, Department of Conservative
Dentistry and Endodontics, Maulana Azad Institute of Dental
Sciences, MAMC Complex, New Delhi - 110 002, India.
E-mail: r_roongta@yahoo.com
Date of submission : 11.03.2013
Review completed : 12.05.2013
Date of acceptance : 30.05.2013
Original Article
A survey of attitude and opinions of endodontic
residents towards regenerative endodontics
Shivani Utneja, Ruchika Roongta Nawal, Mohammed Irfan Ansari
1
, Sangeeta Talwar, Mahesh Verma
2
Departments of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences and
1
Jamia Milia Islamia, Faculty of
Dentistry,
2
Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
A b s t r a c t
Aim: The objective of this survey was to study the level of awareness, current state of knowledge and opinions towards
regenerative endodontic treatments amongst the endodontic residents of India.
Settings and Design: Questionnaire based survey was designed.
Materials and Methods: After approval from the organizing committee of 26
th
Federation of Operative Dentistry of India
and 19
th
Indian Endodontic Society National conference 2011, 200 copies of the questionnaire were circulated amongst
the endodontic residents in conservative dentistry and endodontics at various colleges across the country about regenerative
endodontic procedures. The survey included profile of the respondents and consisted of 23 questions about their knowledge,
attitude and opinions regarding use of these procedures as part of future dental treatment.
Results: The survey showed that half the participants (50.6%) had received continued education in stem cells and/or regenerative
dental treatments. The majority of participants were of the opinion (86.6%) that regenerative therapy should be incorporated
into dentistry, and most of them (88%) were willing to acquire training in learning this new treatment strategy. The results
indicated that half of the participants (52.6%) were already using some type of regenerative therapy in their clinical practice;
however, with a majority of these limited to use of membranes, scaffolds or bioactive materials.
Conclusions: These results reflect that endodontic residents are optimistic about the use of regenerative endodontic procedures;
however, a need for more research and training was felt.
Keywords: Regenerative endodontics; stem cells; tissue engineering
INTRODUCTION
Regeneration of dentin-pulp complex is the long-term goal
of endodontics and restorative dentistry. Recently, there has
been an increasing interest in applying the concept of tissue
engineering to endodontics. The creation and delivery of
new tissues to replace diseased, missing, or traumatized
pulp is referred to as regenerative endodontics.
[1]
Potential
technologies for regenerative endodontics include root canal
revascularization, post natal stem cell therapy, pulp implant,
scaffold implant, three dimensional cell printing, injectable
scaffold and gene therapy.
[2]
A growing body of evidence is
demonstrating the possibility for regeneration of tissues
within the pulp space and continued root development in
teeth with necrotic pulps and open apexes. Recent case
reports from multiple authors support the feasibility of
such regenerative endodontic procedures (REPs).
[3-10]
The
future application of regenerative and tissue-engineering
techniques to dentistry holds immense potential for
meeting a variety of patient needs.
[11]
The next decade of dentistry is speculated to see
unparalleled advances in the field of regenerative
endodontics. However, there is a need for translation of
this novel therapy from labs to the clinics which requires
high quality research coupled with collaboration between
basic scientists and clinicians.
[2]
For the same to occur,
detailed knowledge of REPs and adequate skills in
performing them is of prime importance. Epelman et al.
conducted a survey to understand the attitude of the
dental practitioners towards this new era of treatment.
[12]

This study was limited to a small section of endodontists
who were members of the college of diplomats of the
American Board of Endodontics. More recently another
similar survey was carried out amongst the US dentists
training in different specialties by Manguno et al.
[13]
There is
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DOI:
10.4103/0972-0707.114357
Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics
315 Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4
a need to survey health-care providers in other geographic
locations also, that would help in understanding the
global awareness on this topic. No evidence in the
scientific literature exists that provides information about
the opinions, understanding and attitudes of endodontists
in India regarding the delivery of REPs. This survey was
thus designed similar to the earlier ones and was carried
out on a much larger scale amongst the endodontic
residents studying across all institutions in India. These
residents are the upcoming generation of endodontists
in the nation and form the bulk of potential practitioners
and research associates in the next decade. Hence, it is
important to understand their opinions, level of awareness
and potential acceptance towards this advancement in
endodontics. This will also help in ascertaining if more
emphasis needs to be given to teaching REPs in the post
graduate curriculum and alterations if any are required
in the teaching curriculum of the residents pertaining to
REPs.
Indian Council of Medical Research has established certain
guidelines for stem cell research in which the ethics of
using stem cell therapies for dental treatment have not
been emphasized.
[14]
The opinion of the residents might
be useful in reframing the guidelines for the safety of
regenerative endodontic treatments.
MATERIALS AND METHODS
After approval from the organizing committee, 200
copies of the questionnaire were circulated at the
26
th
Federation of Operative Dentistry of India, and 19
th

Indian Endodontic Society National conference 2011 held
at New Delhi, amongst the endodontic residents pursuing
post-graduation in conservative dentistry and endodontics
at various colleges across the country on the issue of REPs.
The survey consisted of two parts. The first part contained
questions regarding profile of respondents including year
of study, age, sex, and demographics. The second part
contained 23 questions regarding knowledge and opinions
about the use of REPs and their application in a clinical
scenario.
The questionnaire data was analyzed by the number of
responses as a percentage of the total responses to gain
an insight into the majority opinions of the participants as
done previously by Epelman et al.
[12]
RESULTS
Out of 200 copies of the questionnaire which were
circulated 150 completed surveys were received yielding an
overall response rate of 75%. Some participants gave more
than one reply to each question or did not reply to each
question. The questionnaire results are shown in Table 1.
Table 1: A survey of attitude and opinions of
endodontic residents of India towards regenerative
endodontics
% (n)
Profile of participants
Specify your age
Less than 35 100 (150)
More than 35 0 (0)
What is your sex?
Male 41.3 (62)
Female 58.6 (88)
Indicate the location of your post graduate study
North India 24.6 (37)
South India 41.3 (62)
East India 0.6 (1)
West India 10 (15)
Practiced hours per week
Less than 20 h 6.6 (10)
More than 20 h 93.3 (140)
Knowledge, attitude and opinion towards REPs
Have you ever received continued education in stem cells
and/or regenerative dental treatments?
Yes 50.6 (76)
No 49.3 (74)
Should regenerative therapy be incorporated into
dentistry?
Yes 86.6 (130)
No 7.3 (11)
May be 6 (9)
Have you or any of your relatives used umbilical cord or
other types of stem cell banking?
Yes 14.6 (22)
No 80.6 (121)
Unsure 4.6 (7)
Do you think that dental stem cell banking will be useful
to be able to regenerate dental tissues?
Yes 84.6 (127)
No 4 (6)
Unsure 11.3 (17)
How many years do you think it will take for some
regenerative stem cell therapies to be used in dentistry?
0-10 years 70.6 (106)
11-20 years 21.3 (32)
More than 21 years 7.3 (11)
Never 0.6 (1)
How many years do you think it will take before dentists
are able to implant new teeth grown in a laboratory?
0-10 years 36 (54)
11-20 years 41.3 (62)
More than 21 years 20 (30)
Never 2.6 (4)
Would you be willing to attend a training course and/
or continuing education courses to apply regenerative
dental treatments?
Yes 88 (132)
No 4 (6)
Unsure 8 (12)
What do you think would be the biggest obstacle to a
patient accepting regenerative dental treatment?
Higher cost 74.6 (112)
Fear of stem cells 12 (18)
Other reasons 13.3 (20)
Would you be willing to save teeth and dental tissue for
future regenerative dental treatment?
Yes 87.3 (131)
No 2.6 (4)
Unsure 10 (15)
Contd...
Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics
Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 316
Table 1: Contd...
% (n)
Do you think that regenerative dental treatment will be a
better treatment option than tooth implant placement?
Yes 83.3 (125)
No 4 (6)
Unsure 12.6 (19)
Do you think stem cells and regenerate treatments should
be tested on animals prior to clinical testing?
Yes 83.3 (127)
No 5.3 (8)
Unsure 10 (15)
Do you believe that dental professional associations
should regulate the use of stem cell and regenerative
dentistry?
Yes 85.3 (128)
No 6.6 (10)
Unsure 8 (12)
Clinical application of REPs
Do you use any type of regenerative procedures in your
practice, such as membranes, scaffolds or bioactive
materials?
Yes 52.6 (79)
No 47.3 (71)
What is your assessment of regenerative dental
treatment outcomes?
Successful 46.6 (70)
Unsuccessful 8 (12)
Dont know 45.3 (68)
After nonsurgical root canal treatment, would the
healing of periapical tissues be enhanced by tissue
engineering?
Yes 77.3 (116)
No 3.3 (5)
Dont know 19.3 (29)
Which of the following regenerative endodontic
treatments is the most valuable?
Healing of periradicular bone 8.6 (13)
Continued root development in immature teeth 9.3 (14)
Pulp tissue revitalization within a root canal 20 (30)
Tooth re-implantation 2 (3)
All of the above 60 (90)
What percentage of cases in your practice involves
necrotic immature teeth?
Less than 10% 22 (33)
11-25% 48 (72)
26-50% 20 (30)
More than 50% 10 (15)
What percentage of cases in your practice involves
avulsed or traumatized teeth?
Less than 10% 54 (81)
11-25% 28.6 (43)
26-50% 14 (21)
More than 50% 3.3 (5)
What percentage of cases in your practice involves
periradicular lesions?
Less than 10% 10 (15)
11-25% 22.6 (34)
26-50% 38.6 (58)
More than 50% 28.6 (43)
What do you consider to be the optimal treatment for
necrotic immature teeth?
Calcium hydroxide apexification 3.3 (5)
Calcium hydroxide application followed by MTA apical
plug and backfilling with obturation material
54 (81)
MTA apical plug and back-fill with obturation material 25.3 (38)
Tribiotic paste and pulpal regeneration 17.3 (26)
Contd...
Table 1: Contd...
% (n)
Wo'uld you be willing to collect dental tissue for stem
cell banks?
Yes 76.6 (115)
No 5.3 (8)
Unsure 18 (27)
What should the cost for regenerative dentistry be?
Equal to current treatment 28.6 (43)
More than current treatment 50.6 (76)
Less than current treatment 6 (9)
Unsure 14.6 (22)
What would make you most likely to recommend stem
cell and regenerative dental treatments to your patients?
If it is the most effective treatment option 53.3 (80)
It is safe and reliable 40 (60)
If it is the most cost-effective option 6 (9)
I would never recommend it 0.6 (1)
RPEs: Regenerative endodontic procedures, MTA: Mineral trioxide aggregate
Prole of participants
All the participants were in the age group of
25-35 year. (58.6%) of the respondents were females
and (41.3%) were males. (41.3%) of students who
participated were from South Indian colleges, (24.6%)
were from North India, (10%) of participants belonged to
colleges from West India and only one respondent was from
East Indian college. Remaining (23.3%) participants had not
mentioned the location of their post-graduation study. The
majority (93.3%) of endodontic residents devoted more
than 20 h/week in clinics.
Knowledge, attitude and opinion towards REPs
Half the participants (50.6%) had received continued
education in stem cells and/or regenerative dental
treatments. The majority of participants were of the
opinion (86.6%) that regenerative therapy should be
incorporated into dentistry. However, very few of
them (14.6%) had used umbilical cord or other types of
stem cell banking for themselves or a relative. Most of the
respondents (84.6%) believed that stem cell banking would
be useful to regenerate dental tissues. More than two
third of participants (70.6%) also thought that regenerative
stem cell therapies will be used in dentistry within the
next decade. More than one third of participants (41.3%)
felt that it will be possible to implant new teeth grown
in a laboratory in the next 11-20 years. Majority of the
participants (88%) were willing to attend training in REPs.
Two third of participants (74.6%) thought the greatest
obstacle to a patient accepting REPs would be higher cost
of treatment, (12%) thought it would be fear of stem cell
therapy and the remaining (13.3%) thought it would be
due to other reasons. The majority of participants (87.3%)
were willing to save teeth and dental tissues for use as
part of future REPs. Three fourth of participants (83.3%)
thought that REPs could be a more successful treatment
than implants, (12.6%) were unsure, and remaining (6%)
of the participant didnt consider that REPs could be a
Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics
317 Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4
better treatment than implant. Majority of participants
(83.3%) were of the opinion that REPs should be tested
on animals before clinical testing. Most of the participants
(85.3%) agreed that the dental professional association
should regulate the use of stem cell therapies; only (6.6%)
participants didnt want regulation and (8%) were unsure.
Clinical application of REPs
Half of the participants (52.6%) were already using some
type of regenerative therapy in their clinical practice, such
as membranes, scaffolds or bioactive materials; while
the remaining (47.3%) had not used any regenerative
therapies during their post graduate training. (46.6%)
of participants responded that regenerative treatment
would be successful, (45.3%) participants did not
know if the outcome of REPs would be successful; few
participants (8%) thought it would be unsuccessful. The
majority of participants (77.3%) reported that the healing
of periapical tissues could be enhanced by REPs. (19.3%)
of participants did not know if the healing of periapical
tissues could be enhanced by tissue engineering,
whereas only five participants (3.3%) thought it would
not be enhanced. The participants felt the most valuable
application of REPs to be for the pulp tissue revitalization
within a root canal (20%). The next would be continued root
development in immature teeth as indicated by (9.3%) of
participants. 13 (8.6%) agreed that REPs could be used to
heal periradicular bone and three (2%) participants thought
this kind of treatment could be used to replace avulsed
teeth. Majority of participants (60%) however believed that
REPs could be applied to all the above mentioned clinical
situations. Almost half the participants (48.5%) reported
that they come across necrotic immature teeth in 11-25%
of their cases. (22%) participants indicated that necrotic
immature teeth accounted for less than 10% of cases in
their Out-Patient Department (OPD). (20%) responded that
25-50% of their cases involved necrotic immature teeth and
15 of them (10%) reported to have more than 50% of such
cases in their OPD. Half of the participants (54%) reported
that avulsed or traumatized teeth account for less than 10%
of their OPD cases. One third participants (38.6%) reported
that periradicular lesion accounted for between 26%
and 50% of cases seen in their OPD. (28.6%) participants
indicated that even more than 50% of cases in their OPD
involved periradicular lesions; (22.6%) indicated such
cases to be between 11% and 25%, while remaining 10%
reported that occurrence of such cases to be less than
10%. More than half of the participants (54%) consider
the application of calcium hydroxide followed by mineral
trioxide aggregate (MTA) apical plug and backfilling with
obturation material to be the optimum treatment for
necrotic immature teeth. Only one eighth participants
agreed that application of triple antibiotic paste and pulp
regeneration would be the optimum treatment for necrotic
immature teeth. Majority of participants (76.6%) were
willing to collect dental tissue for stem cell bank. Most
of the participants (50.6%) believe that the cost of REPs
should be more than current treatment. The majority of
participants (53.3%) would recommend stem cell treatment
and REPs to their patients if it was the most effective
treatment option.
DISCUSSION
The discovery of stem cells in the pulp of permanent and
deciduous teeth raised the intriguing possibility of using
dental pulp stem cells for tissue engineering.
[15]
Recent
advances in the identification and characterization of dental
stem cells, and in dental tissue-engineering strategies,
suggest that within the next decade, bioengineering
approaches may successfully be used to regenerate dental
tissues and whole teeth.
[11]
In order for this approach
to reach clinical relevance in human, adequate interest
and knowledge backed by research amongst the service
providers is the prime requisite. This survey was hence
conducted to collect data about the level of awareness,
knowledge and present clinical status about stem cell
therapies and REPs amongst the endodontic residents
of our country. The survey yielded a very enthusiastic
response from the residents, wherein nine out of ten
felt that regenerative therapy should be incorporated
into dentistry. More than two third of participants were
optimistic about its use in dentistry in the next decade, and
nearly one third felt this new approach would be successful
to the level of possibility of implanting laboratory grown
teeth. This positive response could be due to the recent
surge in public discussions on this topic through various
forums including an increase in tissue engineering articles
published in scientific journals, talks based on stem cell
therapies and news dominating dental and medical
tribunals.
[16,17]
Most residents were willing to save teeth and dental
tissues through REPs and preferred it over implants as
a treatment option, However, almost all felt a need to
attend training in REPs, reflecting an underlying lack of
knowledge. According to the majority of respondents
another prerequisite to carry out REPs would be
proper ethical regulation by the respective professional
associations. Epelman et al. in their study also stressed
on the importance of such regulations to come in place.
[12]

For REPs to become the mainstay of treatment modalities
a strong research backing is warranted; wherein most
respondents felt that these should be tested on animals
before clinical application. In spite of enthusiasm and
willing attitude, only one fifth respondents had used
stem cell banking for themselves or relatives. In fact,
they felt that the biggest deterrent for patients to accept
this treatment modality would be the fear of stem cells,
followed by the high cost. In their opinions, REPs should
be priced such that it is equally affordable to patients as
other standard procedures.
Utneja, et al.: A survey of dental residents attitudes for regenerative endodontics
Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4 318
In clinical practices, almost half of the residents were doing
some type of REPs, with a majority of these limited to use
of membranes, scaffolds or bioactive materials. Most of the
residents were aware of other REP procedures but were
unsure about its results. Half of them were of the opinion
that REPs could be used in various applications like healing
of periradicular bone, continued root development in
immature teeth, pulp tissue revitalization within a root
canal and tooth re-implantation. However, only one eighth
respondents have found regenerative techniques valuable
in treating necrotic immature teeth which constituted
20% of patients reporting to them. More than half of
the participants still consider the application of calcium
hydroxide followed by MTA apical plug and backfilling
with obturation material to be the optimum treatment for
necrotic immature teeth. This gives an insight to the fact
that the residents are not trained in performing advanced
regenerative endodontic techniques. There is a need for
continuing education and training programs related to
all treatments that accomplish pulp-dentin regeneration
from the simplest blood clot revascularization method
to the most complex treatment, which involves creating
tissue-engineered dental pulp constructs in the laboratory
and implanting them into cleaned and shaped root canals.
Safeguards have to be in place to protect research
participants receiving stem cell transplants, and patients at
large from receiving unproven stem cell therapies. In India,
Indian Council of Medical Research has taken an initiative
to lay down the guidelines pertaining to stem cell research
which were revised in March 2012.
[14]
These apply to all
stakeholders viz. individual researchers, organizations,
sponsors, oversight committees and others, associated
with research on human stem cells and for their derivatives,
both basic and clinical. However, there is a need for the
creation of more expansive guidelines covering all REPs in
addition to these guidelines to protect patients and health
care providers.
CONCLUSION
The survey participants expressed general optimism and
at the same time showed a consensus on the need for
research and training towards REPs. An impending need
was felt amongst the residents for ethical regulation
of REPs and guidelines for protecting patients by local
governing bodies. More survey research like this should
be conducted amongst health-care providers in other
geographic locations that would help in understanding the
global awareness on this topic. This data along with further
research would help in standardizing REPs worldwide.
ACKNOWLEDGMENT
We would like to sincerely thank Dr. Sanjay Miglani, Organising
Secretary of the Federation of Operative Dentistry of India/
Indian Endodontic Society conference, New Delhi for giving his
guidance and support.
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How to cite this article: Utneja S, Nawal RR, Ansari MI, Talwar
S, Verma M. A survey of attitude and opinions of endodontic
residents towards regenerative endodontics. J Conserv Dent
2013;16:314-8.
Source of Support: Nil, Conict of Interest: None declared.

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