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The use of cone-beam computed tomography in localizing calcified canals during endodontic treatment, Almohaimede AA. Saudi Endod J 2018;8:217-21

176 © 2018 Saudi Endodontic Journal | Published by Wolters Kluwer ‑ Medknow

A Survey on Restorative Methods to Rehabilitate Endodontically Treated Anterior Teeth by Dental Students and New Graduates of King Saud University

Sahar A. AlZainDepartment of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Original Article

INTRODUCTION

It is challenging to obtain optimal results in the restoration of endodontically treated teeth (ETT). Several factors influence the selection of restoration of ETT such as the amount of remaining coronal tooth structure, tooth type, and position in the dental arch and whether the tooth

should serve as an abutment for a fixed or removable partial denture (FPD/RPD). The amount of coronal remaining tooth structure is one of the main factors to be considered during the planning of the restorative phase of ETT. Maximum preservation of coronal and radicular sound tooth structure is always recommended. This is

Aim: The aim of the study was to evaluate the ability and efficiency of dental students and new graduates of College of Dentistry at King Saud University in Riyadh to select the appropriate methods of restoring endodontically treated anterior teeth (ETAT) at different conditions.Materials and Methods: A questionnaire was distributed among 4th‑and 5th‑year dental students and new graduates of College of Dentistry at King Saud University in Riyadh. Only students who were pursuing clinical training in prosthodontics were included in this study. Respondents were requested to indicate their gender, level of education, and to select the preferred restoration of ETAT at different conditions. The results were analyzed by one‑way frequency and two‑way cross‑tabulations.Results: The response rate was 98%. When more than 50% of tooth remains A, 94.4% of respondents selected a tooth‑colored restoration, whereas 37.3% selected a tooth‑colored restoration and a crown when 50% of tooth remains B. When <50% of tooth remains C, 53.6% selected a cast post and core and a crown. Statistically significant relationships existed between the selected restorative method at B and the gender (P = 0.005) and level of education (P = 0.000) and between the restorative method at C and the level of education (P = 0.016). When teeth serve as abutments for fixed or removable partial dentures, more advanced methods of restoration were selected.Conclusions: Selection of the appropriate method of restoring ETAT at different clinical conditions by students and new graduates was evident.

Keywords: Anterior teeth, dental students, endodontically treated teeth, new graduates, restoration

Abstract

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Website:www.saudiendodj.com

DOI:10.4103/sej.sej_7_18

Address for correspondence: Dr. Sahar A. AlZain, P. O. Box: 102247, Riyadh 11675, Saudi Arabia. E‑mail: [email protected]

How to cite this article: AlZain SA. A survey on restorative methods to rehabilitate endodontically treated anterior teeth by dental students and new graduates of king saud university. Saudi Endod J 2018;8:176-82.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

AlZain: Restoration of endodontically treated teeth

Saudi Endodontic Journal | Volume 8 | Issue 3 | September-December 2018 177

because the amount of remaining tooth structure is an important factor in fracture resistance.[1,2] Selection of the optimal restoration to compensate for the lost coronal tooth structure of ETT is considered the key to successful restorative outcomes.

Teeth with minimal coronal damage (much more than 50% of tooth remaining) require only direct composite restoration to restore the endodontic access cavity.[3‑6] The unrestored ETT is susceptible to fracture, which could lead to loss of the tooth.[7]

Prefabricated fiber post and direct composite restoration was considered as a treatment option for restoring ETT with moderate coronal damage (approximately 50% of coronal tooth structure remaining).[6] A post is primarily used to retain a core. A 30‑month clinical observational study showed favorable results of previously restored ETT with fiber post and direct resin composites.[8] Conservation of tooth structure and good patient compliance were the main advantages.[8] Teeth restored with composite resin or fiber posts and composite resin resisted fatigue tests.[9] Teeth restored with a glass fiber‑reinforced post with a composite core and a crown demonstrated favorable fractures that were restorable.[10] However, ETT restored with a stainless steel post with a composite core showed the highest fracture resistance when compared to those restored with composite restoration, glass fiber post, and composite core or cast post‑and‑core.[10] The least fracture resistance was demonstrated by ETT that were restored with a composite restoration.[10]

A tooth with significant coronal damage (<50% of the coronal tooth structure remaining) often requires a post to retain a core buildup followed by a crown restoration.[3‑6,11] Posts are obviously mandatory for restoring ETT when there is insufficient retention of the core.[3‑6,11] Hinckfuss and Wilson[9] stated that “post placement should become an exception rather than a rule.” However, in some cases where there is a need to increase the stability of the foundation of the crown restoration, a fiber post is preferred due to its physical properties being close to natural teeth.[8,9,12,13]

ETT was found to serve well as abutments for FPD/RPD. Goga and Purton[1] stated that “using ETT as distal abutments of a cantilever FPD should be avoided.” This is because it severely compromises the biomechanical stability of the biologic and restorative structures.[14] In this case, conserving tooth structure, using nonrigid connectors, developing a ferrule effect, providing a proper design, and planning a regular professional maintenance program should be considered.[1]

The purpose of this survey study was to evaluate the ability and efficiency of dental students and new graduates of College of Dentistry at King Saud University in Riyadh, Saudi Arabia, to select the appropriate methods of restoring endodontically treated anterior teeth (ETAT) at different conditions of remaining sound tooth structure and to indicate the effect of their gender and level of education on selection of the restorative method.

MATERIALS AND METHODS

A questionnaire was designed, validated, and distributed among 4th‑ and 5th‑year dental students and new graduates of the College of Dentistry at King Saud University in Riyadh. Respondents were directly approached and asked to respond to the questionnaire. Questionnaires were then collected and the response rate was 98%. Respondents were asked to indicate their gender and level of education. Only students who were pursuing clinical training in prosthodontics were included in this study. The questionnaire contained different choices of restorative treatment methods for restoring ETAT at different conditions (percentages) of remaining sound tooth structure (>50%, =50%, and <50%). One or more of these conditions (percentages) were used in some studies as a guide to restore teeth.[11,15] Respondents were asked to indicate their preferred method of restoration of those teeth. They were also asked to indicate whether the chosen method would change if the same tooth at the same condition of remaining sound tooth structure was used as an abutment for FPD/RPD. A total of 233 responses were collected.

Statistical analysisIBM Statistical Package for the Social Sciences (IBM SPSS version 20, Chicago, IL, USA). One‑way frequency tables were generated to summarize the responses. Two‑way cross‑tabulations were analyzed to show the associations between the preferred method of restoration and the gender and level of education.

RESULTS

Condition A (more than 50% of sound tooth structure remaining)Results showed that the majority of respondents (94.40%) preferred to restore the ETAT with a tooth‑colored restoration [Table 1]. This method was preferred more by a male (97.20%) than female students (89.60%) [Table 2] and more by 4th‑year students (97.60%) [Table 3]. Chi‑square analysis demonstrated no statistically significant relationship between the selected restorative method and the gender or level of education. When the same tooth is used as an abutment for FPD/RPD, respondents


178 Saudi Endodontic Journal | Volume 8 | Issue 3 | September-December 2018

who preferred to use a tooth‑colored restoration were much reduced to be only 42.28% [Table 4]. Under this condition, more respondents (42.28%) preferred to restore the tooth with the tooth‑colored restoration followed by a crown. Both restorative methods were preferred more by males than females as shown in Table 5. The tooth‑colored restorative method was preferred more by 4th‑year students (54.60%), whereas restoring the tooth with the same restoration followed by a crown was preferred more by 5th‑year students (47.8%) [Table 6]. Statistically significant relationships were demonstrated between the selected restorative method and the gender (P = 0.015) and level of education (P = 0.018) when the tooth is used as an abutment for FPD/RPD.

Condition B (approximately 50% of sound tooth structure remaining)Tooth‑colored restoration followed by a crown restoration was preferred by 37.30% of the respondents [Table 1], more by the female students (42.50%) [Table 2], and more by the new graduates (58.60%) [Table 3]. Comparable percentages of the respondents preferred to use a tooth‑colored post combined with a tooth‑colored restoration and the same post and tooth‑colored restoration followed by a crown restoration (26.10% and 29.10%, respectively). The tooth‑colored post combined with a tooth‑colored restoration followed by a crown was preferred more by male students (34.90%) and more by the 5th‑year students (44.40%). Chi‑square analysis demonstrated statistically significant relationships between the selected restorative method and the gender (P = 0.005) and level of education (P = 0.000). When the same tooth is used as an abutment for a FPD/RPD, 54.50% of respondents preferred to use a tooth‑colored post with a tooth‑colored restoration followed by a crown restoration [Table 4], more by female students (59.70%) than male (50.90%) [Table 5], and more by 5th‑year students (61.40%) [Table 6]. Chi‑square analysis demonstrated no statistically significant relationship between the selected restorative method and the gender or level of education of the respondents when the tooth is used as an abutment for (FPD/RPD).

Condition C (less than 50% of sound tooth structure remaining)Results showed that 53.60% of respondents preferred to use a cast post and core and a crown restoration [Table 1], much more by male students (58.20%) [Table 2], and more by 5th‑year students (68.80%) [Table 3]. The use of a tooth‑colored post restoration combined with a tooth‑colored restoration followed by a crown restoration was preferred by 36% of respondents, slightly more by female students (41.30%), and more by 4th‑year students (47%). Chi‑square analysis

Table 1: Overall frequency and percentage of respondents using different methods of restoring endodontically treated teeth with different amount of remaining sound tooth structure*Method of restoration Amount (%) of remaining sound

tooth structureA (>50%) B (50%) C (<50%)

A tooth‑colored restoration (composite, glass ionomer)

220 (94.40) 2 (0.85) 1 (0.42)

A tooth‑colored restoration and a crown restoration

7 (3.00) 87 (37.30) 1 (0.42)

A tooth‑colored post (fiber/zirconium) and a tooth‑colored restoration

2 (0.85) 61 (26.10) 12 (5.15)

A prefabricated stainless steel post and a tooth‑colored restoration

0 (0.00) 4 (1.71) 2 (0.85)

A tooth‑colored post (fiber/zirconium), a tooth‑colored core and a crown restoration

2 (0.85) 68 (29.10) 84 (36.00)

A prefabricated stainless steel post and a tooth‑colored core and a crown restoration

0 (0.00) 10 (4.29) 8 (3.43)

A cast post‑and‑core and a crown restoration

2 (0.85) 1 (0.42) 125 (53.60)

Total 233 233 233

*χ2 (df ≥2)

Table 2: Frequency and percentage of respondents using different restorative methods of remaining sound tooth structure compared with gender*Method of restoration Amount (%) of remaining sound tooth structure

A (>50%) B (50%) C (<50%)Male Female Male Female Male Female

A tooth‑colored restoration (composite, glass ionomer) 142 (97.20) 78 (89.60) 0 (0.00) 2 (2.20) 0 (0.00) 1 (1.10)A tooth‑colored restoration and a crown restoration 3 (2.00) 4 (4.5) 50 (34.20) 37 (42.50) 0 (0.00) 1 (1.10)A tooth‑colored post (fiber/zirconium) and a tooth‑colored restoration 0 (0.00) 2 (2.20) 31 (21.20) 30 (34.40) 6 (4.10) 6 (6.80)A prefabricated stainless steel post and a tooth‑colored restoration 0 (0.00) 0 (0.00) 3 (2.0) 1 (1.1) 0 (0.00) 2 (2.20)A tooth‑colored post (fiber/zirconium), a tooth‑colored core, and a crown restoration

0 (0.00) 2 (2.20) 51 (34.90) 17 (19.50) 48 (32.80) 36 (41.30)


0 (0.00) 0 (0.00) 9 (6.10) 1 (1.10) 7 (4.70) 1 (1.10)

A cast post‑and‑core and a crown restoration 1 (0.60) 1 (1.10) 1 (0.60) 0 (0.00) 85 (58.20) 40 (45.90)P-value 0.079 0.005 0.056

*χ2 (df ≥2)



demonstrated a statistically significant relationship between the selected restorative method and the level of education (P = 0.016). When the same tooth is used as an abutment for a FPD/RPD, 68.7% of respondents preferred to use the cast post and core and a crown restoration [Table 4], more by 5th‑year students (77.10%) [Table 6], and with comparable

responses from the male and female students (69.20% and 68%, respectively) [Table 5]. Chi‑square analysis demonstrated no statistically significant relationship between the selected restorative method and the gender or level of education when the tooth is used as an abutment for (FPD/RPD).

DISCUSSION

In this study, 94.40% of respondents preferred to restore the ETAT with the majority (more than 50%) of their tooth structure remaining using a tooth‑colored restoration. This is supported by other studies that also suggested restoration of ETT with the composite resin to preserve maximum tooth structure.[2‑7] However, the least fracture resistance was demonstrated by teeth with intact coronal tooth structure except for access cavities, which were restored with composite restorations.[10]

Most of the respondents (29.10%) preferred to restore the tooth with 50% of its structure remaining with a tooth‑colored restoration followed by a crown restoration. However, a tooth‑colored post and a tooth‑colored restoration were still preferred (26.10%). Gonzaga et al.[6] and Ratnakar et al.[7] stated that “when half of tooth structure remains, a prefabricated glass fiber post followed by direct composite resin restoration may be used.” When marginal ridges are intact and the tooth has a deep pulp chamber, a composite resin restoration is used without a post.[6] Cagidiaco et al.[16] evaluated post‑and‑core restorations after a 2‑year clinical service. They found that only 4.3% of cases experienced debonding of fiber posts.

Table 4: Overall frequency and percentage of respondents using different methods of restoring endodontically treated teeth with different amount of remaining sound tooth structure when the tooth is used as an abutment for a fixed or removable partial denture*Method of restoration Amount (%) of remaining sound

tooth structureA (>50%) B (50%) C (<50%)


74 (42.28) 0 (0.00) 0 (0.00)


74 (42.28) 24 (13.60) 2 (1.13)


11 (6.28) 30 (17.00) 1 (0.56)


0 (0.00) 13 (7.38) 3 (1.70)

A tooth‑colored post (fiber/zirconium), a tooth‑colored core, and a crown restoration

15 (8.57) 96 (54.50) 36 (20.40)


0 (0.00) 10 (5.68) 13 (7.38)


1 (0.57) 3 (1.70) 121 (68.70)

Total 175** 176 176

*χ2 (df ≥2), **One respondent preferred to change restorative method when the tooth at condition A is used as an abutment for FPD/RPD, but did not select any of the methods

Table 3: Frequency and percentage of respondents using different restorative methods of remaining sound tooth structure compared with level of education (4th‑year, 5th‑year, and new graduates)*Method of restoration Amount (%) of remaining sound tooth structure

A (>50%) B (50%) C (<50%)4th‑year 5th‑year NG 4th‑year 5th‑year NG 4th‑year 5th‑year NG


83 (97.60) 84 (93.30) 53 (91.30) 0 (0.00) 0 (0.00) 2 (3.40) 1 (1.10) 0 (0.00) 0 (0.00)


1 (1.10) 3 (3.30) 3 (5.10) 34 (40) 19 (21.10) 34 (58.60) 0 (0.00) 1 (1.10) 0 (0.00)


0 (0.00) 1 (1.10) 1 (1.70) 26 (30.50) 23 (25.50) 12 (20.60) 3 (3.50) 3 (3.30) 6 (10.30)


0 (0.00) 0 (0.00) 0 (0.00) 2 (2.30) 2 (2.20) 0 (0.00) 0 (0.00) 1 (1.10) 1 (1.70)

A tooth‑colored post (fiber/zirconium), a tooth‑colored core, and a crown restoration

1 (1.12) 0 (0.00) 1 (1.70) 21 (24.70) 40 (44.40) 7 (12.00) 40 (47.0) 22 (24.40) 22 (37.90)


0 (0.00) 0 (0.00) 0 (0.00) 2 (2.30) 6 (6.60) 2 (3.40) 3 (3.50) 1 (1.10) 4 (6.80)


0 (0.00) 1 (1.10) 1 (1.70) 0 (0.00) 0 (0.00) 1 (1.70) 38 (44.70) 62 (68.80) 25 (43.10)

P-value 0.723 0.000 0.016

*χ2 (df ≥2). NG: New graduates



In this study, the majority of respondents (53.60%) preferred to restore the tooth with <50% of its structure remaining with a cast post‑and‑core followed by a crown restoration. This was supported by the study of Ratnakar et al.[7]

A glass fiber post is strongly recommended because of its modulus of elasticity being close to that of dentin and its good fracture resistance.[8,9,12] In 2011, Dejak and Młotkowski[17] performed a finite element analysis study and showed that cast metal posts with a high elastic modulus resulted in lower stresses in the cervical dentin than did glass fiber‑reinforced posts. They concluded that ceramic crowns supported by cast posts and cores were more resistant to failure than those supported by fiber posts and composite resin cores.[17] However, results of a 3‑year clinical follow‑up showed comparable success rates of fiber posts and cores compared with cast posts‑and‑cores (91.70% and 97.20% respectively), but they recommended longer follow‑up periods.[18] Like metal posts, zirconium posts are difficult to be retrieved because of their high rigidity and hardness

and cannot be etched, so it cannot bond to a composite core. Ceramic posts and cores may be indicated for restoration of ETAT due to their higher fracture strengths than the occlusal force of natural dentition.[19] In a recent retrospective study of ETT in 1298 patients, only 13.9% were classified as restorative failures due to tooth fractures and the need to replace previous restorations.[20] The authors found that ETT without posts or with fiber posts experienced more restorative failures than ETT restored with metal posts.[20] However, they stated that this may be due to the smaller number of fiber compared to metal posts that were involved in their study.[20] Post placement decreases the amount of the remaining tooth structure, thus weakening the already structurally compromised tooth. Furthermore, tooth preparation may weaken the tooth and increase the risk of root fracture.[6] Therefore, the decision to use a post should be made carefully.

A guide was introduced in 2001 by Weigl and Heidemann and modified in 2009 by Vârlan et al.[11] to help and

Table 5: Frequency and percentage of respondents using different restorative methods of remaining sound tooth structure when the tooth is used as an abutment for a fixed or removable partial denture compared with gender*Method of restoration Amount (%) of remaining sound tooth structure

A (>50%) B (50%) C (<50%)Male Female Male Female Male Female

A tooth‑colored restoration (composite, glass ionomer) 47 (45.10) 27 (38.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00)A tooth‑colored restoration and a crown restoration 49 (47.10) 25 (35.20) 14 (13.40) 10 (13.80) 1 (0.90) 1 (1.30)A tooth‑colored post (fiber/zirconium) and a tooth‑colored restoration 3 (2.80) 8 (11.20) 18 (17.30) 12 (16.60) 1 (0.90) 0 (0.00)A prefabricated stainless steel post and a tooth‑colored restoration 0 (0.00) 0 (0.00) 10 (9.60) 3 (4.10) 0 (0.00) 3 (4.10)A tooth‑colored post (fiber/zirconium), a tooth‑colored core, and a crown restoration

5 (4.80) 10 (14.00) 53 (50.90) 43 (59.70) 21 (20.10) 15 (20.80)


0 (0.00) 0 (0.00) 8 (7.60) 2 (2.70) 9 (8.60) 4 (5.50)

A cast post‑and‑core and a crown restoration 0 (0.00) 1 (1.40) 1 (0.90) 2 (2.70) 72 (69.20) 49 (68.00)P‑value 0.015 0.421 0.340

*χ2 (df ≥2)

Table 6: Frequency and percentage of respondents using different restorative methods of remaining sound tooth structure when the tooth is used as an abutment for a fixed or removable partial denture compared with level of education (4th‑year, 5th‑year, and new graduates)*Method of restoration Amount (%) of remaining sound tooth structure

A (>50%) B (50%) C (<50%)4th‑year 5th‑year NG 4th‑year 5th‑year NG 4th‑year 5th‑year NG


35 (54.6) 22 (31.8) 17 (40.4) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00)


25 (39) 33 (47.8) 16 (38) 7 (10.9) 6 (8.5) 11 (26.1) 1 (1.5) 0 (0.00) 1 (2.3)


1 (1.5) 4 (5.7) 6 (14.2) 12 (18.7) 10 (14.2) 8 (19) 0 (0.00) 0 (0.00) 1 (2.3)


0 (0.00) 0 (0.00) 0 (0.00) 7 (10.9) 4 (5.7) 2 (4.7) 1 (1.5) 2 (2.8) 0 (0.00)

A tooth‑colored post (fiber/zirconium), a tooth‑colored core and a crown restoration

2 (3.1) 10 (14.4) 3 (7.1) 35 (54.6) 43 (61.4) 18 (42.8) 14 (21.8) 12 (17.1) 10 (23.8)


0 (0.00) 0 (0.00) 0 (0.00) 3 (4.6) 5 (7.1) 2 (4.7) 7 (10.9) 2 (2.8) 4 (9.5)

A cast post‑and‑core and a crown restoration 1 (1.5) 0 (0.00) 0 (0.00) 0 (0.00) 2 (2.8) 1 (2.3) 41 (64) 54 (77.1) 26 (61.9)P‑value 0.018 0.245 0.349

*χ2 (df ≥2). NG: New graduates



guide practitioners when planning to restore ETAT with different remaining coronal dentinal walls and number of missing surfaces. At normal functional occlusal forces, a tooth with only one surface missing is restored with direct adhesive composite restoration. Teeth with two or three missing surfaces may be restored with an adhesive composite, veneers, or even complete crown restoration in some cases. When the remaining coronal dentinal walls are more than 2 mm, an adhesive composite followed by a crown restoration was recommended. However, in cases of <2 mm coronal dentinal walls, an adhesive composite or post and core followed by crown restorations was advised. In a retrospective study, complete crown restoration of ETT showed a lower failure rate than intracoronal restorations.[20] They stated that complete coverage of the ETT generates a cervical ferrule which improves retention of restoration and protect the compromised remaining tooth structure. Another guide was also introduced in 2001 by Weigl and Heidemann and also modified in 2009 by Vârlan et al.[11] to restore ETAT that serve as abutments for FPD/RPD with increased functional occlusal forces. Crown restorations were recommended for all ETAT with different remaining coronal dentinal walls and number of missing surfaces. Post‑and‑core restorations (prefabricated or cast) were recommended when the remaining coronal dentinal walls are more or <2 mm.

When ETT serves as abutments for FPD/RPD, increased functional loads demand special consideration when selecting the appropriate coronal restoration. In this study, respondents were asked if their choice of restorative method would change in case the tooth is used as an abutment for FPD/RPD. The majority of them (75.5%) preferred to change their treatment of choice to more advanced methods. This indicates the high level of awareness of the students and the new graduates to consider this issue when selecting final restorations of ETT at different conditions of remaining sound tooth structure.

A recent classification for diagnosis and selection of the appropriate treatment option of ETAT was introduced by Murgueitio and Avila‑Ortiz.[3] Several important factors related to the ETT were considered such as remaining tooth height, wall thickness, and circumferential integrity.[3] Other factors related to the root were also considered such as diameter and shape of the canal and depth of the preparation.[3] This classification may also be helpful for clinicians in evaluating ETT.

The prognosis of ETT depends not only on the outcomes of endodontic treatment but also on the selected definitive restoration depending on the amount of remaining coronal

tooth structure. Al Shareef and Abdelhamied[21] concluded that a tooth that has received an endodontic therapy with an adequate restoration represents a good practical and economical way of preservation of function in many cases. However, they stated that a dental implant can serve as a good alternative in cases with poor prognosis.[21]

In this study, the awareness of all respondents of the most appropriate method of restoring ETAT with different amounts of remaining sound tooth structure was evident. Due to different experiences of respondents with the teaching staff/supervisors, there were differences in responses between the two genders as well as within each gender. The effect of gender on the differences in responses was statistically significant only for condition A, when the tooth is used as abutment for FPD/RPD and at condition B of remaining tooth structure. Moreover, the selected method was also influenced by the level of the education. The most preferred restorative method was selected by respondents at different education levels for condition A. However, the selection differences were statistically significant among new graduates for condition B and more by 5th‑year students for condition C. It was evident that, as the student knowledge and clinical experience becomes more advanced, the selection of the restorative method of restoration of ETAT becomes more appropriate.

CONCLUSIONS

Results of this study reflect the high knowledge of respondents when selecting the appropriate restorative method of ETAT. It is recommended to periodically evaluate the clinical experience of restoring teeth by students and new graduates for continuous improvement of teaching and learning and curriculum development.

AcknowledgementThe author acknowledges Mr. Nassr Mefleh, the Biostatistician at the College of Dentistry Research Center (CDRC), for his help in the statistical analysis.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

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volume 8 / issue 3 / september-december 2018

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