Introduction

Exodontia has many complications that became common among dentistry students, general practitioners, post-graduate students, and even oral surgeons during surgical and non-surgical tooth extraction. Government, university and private hospitals and clinics, have all reported it. Significant injuries can result from nerve, bone, and soft tissue injuries. Minor injuries such as tooth root fractures, fractures of the maxillary tuberosity, displacement of the maxillary roots or teeth into the maxillary sinus and of the mandibular teeth in the submandibular space, mobility of the adjacent teeth, and in rare cases, extraction of the wrong tooth could occur [1-5]. These complications vary in their extension and severity, and their rates of occurrence among general dentists and post-graduate candidates. Several factors affect the dentist’s confidence and performance in surgical tooth extraction, in their daily practice that might be related to his/her experience, or even their interest in practicing these surgical procedures. Clinical factors include their exposure to a wide variety of cases, and the quality and length of their received training, while their didactic education is based on their acquired knowledge and cognitive skills. We aspire to focus the spotlight on the most common complications that general dentists and postgraduates produce during teeth extraction, their frequency, how they manage these complications, their immediate actions, regarding whether they inform the patients about the complications confidently or not and recognize the reasons of feeling unconfident to perform and manage particular surgical extraction operations.

Literature review

Literature has been reviewed to learn more about general dentists' and postgraduates' confidence in performing dental extraction and surgical procedures, as well as their ability to manage the procedures’ complications if they occurred, and how they informed their patients about the situations they encountered during the provided service. The gathered information provided us with a key map that paved the road toward proceeding with this study.

Al-Dajani et al. in Aljouf University school of dentistry in Saudi Arabia, used a self-administrated survey questionnaire, distributed among fourth and fifth years dental undergraduate students, assessing and determining their level of confidence in performing dental oral surgical procedures in correspondence with the number of teeth they extracted during their practice [6]. In their study, thirty-two dental students reported studying literature about the subject of oral and maxillofacial surgery for an average of four - seven hours per week. The number of teeth extracted by the students, were 25.3 teeth. Seventy-five percent of the students used sutures after extracting the teeth, and twenty-five percent developed expertise in treating dry socket. In addition, 40.6 percent of students reported that their lower first molar was the first tooth to be extracted, while 56.3 percent of respondents admitted their first extraction was tough. The first extraction process was not deemed "very tough" by anyone. They discovered that through the integration of basic science, and a good dental background, they were able to apply this knowledge to relevant clinical scenarios, which facilitated the efficiency of the learning process. They also discovered that students who performed exodontia more frequently had a higher level of confidence in handling instruments. Students, on the contrary, had a lower confidence level in performing surgical exodontia when compared to simple exodontia [6].

This research aims to spot as well why the general dentist is not confident in some extraction procedures and try to find a solution that could make the new generation of general dentists more confident. Bahammam and Linjawi [7] in another study, were concerned with the future Saudi dentists' knowledge, attitudes, and impediments to utilizing evidence-based practice (EBP). The EBP included a key indicator or competency standard for assessing high-quality patient-centered clinical care solutions, which was created by health organizations. As part of the auditing process, it was called clinical governance. Students in this EBP were not used in the study to order tests or treatment. This could explain their lack of understanding of the value of incorporating EBP into their therapeutic practices. Accordingly, the most significant barrier to EBP use was a lack of understanding of the concept. Their limited access to EBP materials was cited as the most serious problem, while a lack of time in their studies was considered the second most serious problem. Multiple research investigations showed incorporating EBP competencies into healthcare system expectations and operations can improve healthcare quality, consistency, and reliability while also lowering costs according to current research, without a well-designed strategy for integrating EBP into any therapeutic context, the outcome is unknown, and it is usually not worth the effort. The EBP necessitated a professional approach as well as a group of skills, knowledge, and clinical expertise, a culture shift and increased awareness at all levels. This research backs up the idea that EBP integration should be well-structured as a major competency level in graduate curricula, which is essential in Saudi contexts and programs to enable them to evolve [7].

Honey et al., assessed the senior-year dental student's self-confidence at two dental schools; Cardiff and Cork universities [8]. A questionnaire was presented to sixty-one and thirty-four, Cardiff and Cork final-year students respectively to assess their level of self-confidence in performing procedures, often performed in primary dental care clinics, using a five points scale ranging from 1= as the lowest level of confidence, to 5= as the highest level of confidence. Their results proved that the rate of response was seventy-four percent (n=70), and the documented highest level of self-confidence was in performing scaling and polishing (4.61) compared to only (2.26) among dental students in performing surgical tooth extraction. The students at Cardiff, exhibited slightly more confidence, than students at Cork regarding the simple tooth extraction procedure, since Cardiff students recorded (4.31 out of 5), while Cork students, were (3.76 out of 5). Moreover, Cardiff students were also more confident in performing surgical tooth extraction, their level of confidence was (2.61 out of 5), where Cork University students scored (1.88 out of 5) [8].

Shah et al., underwent a study, where they assessed the senior undergraduate students’ confidence and experience in oral surgery procedures, through answering a survey [9]. They found that low confidence levels after graduation resulted in an increased number of referred cases to secondary care centers. This was believed to exert a national economic burden on the NHS, whereas from the patients' standpoint it added to their inconvenience. A survey was given to one hundred and fifty senior students in the school of dentistry at King's College, one month before graduating in the year 2015. Their level of confidence was assessed on oral surgery quota, where the questions were based on scenarios. On the other hand, the surgical procedures started by raising a mucoperiosteal flap, followed by surgical sectioning of the tooth, and finally by suturing. The response rate was shown to be at 71% (107/150), 84% of students had undertaken between 50–79 extractions during their undergraduate study years, and 47% performed around 10–19 surgical extractions.

75% of the students felt they had adequate knowledge and clinical competency as an undergraduate performing oral surgery, no variables between the gender of the students and their confidence level were noted.

At Kuwait University, a cross-sectional study was carried out to evaluate undergraduate students’ confidence in the oral and maxillofacial surgery field. This evaluation aimed to prepare students to face surgical challenges, by enhancing the educational schemes and selecting the required materials and instruments [10]. They compared a total of 39 students between the sixth year (n = 20) and seventh year (n=19), through a validated well- structured questionnaire developed by the Association of British Academic Oral and Maxillofacial Surgeons. It included 17 questions assessing the undergraduates' OMFS curriculum. They found that (61%) of the students showed sufficient amount of confidence in practicing simple dentoalveolar procedures and managing simple surgical complications like; bleeding from a tooth socket, and pericoronitis, while they reported having less confidence in surgical extractions and advanced surgical procedures. They concluded that students favor the use of simple extraction forceps and elevators.

Research question

To assess the level of confidence of dental postgraduate and general dental practitioners in performing uncomplicated and complicated dental extractions.

Research hypothesis

• The level of confidence among postgraduates is higher than among general practitioners.
• Level of education and training influences the level of confidence.

Rationale

To achieve good patient care, avoid some possible complications and unnecessary costs.

Aims & objectives

• To evaluate the competency of the dental postgraduate and general practitioner.
• To assess the quality of treatment in universities, government-owned hospitals, and private hospitals/centers.
• The role of practitioner’s experience in preventing complications.

Significance of the study

• We expect to see the level of confidence among postgraduates affecting the decision-making in managing surgical extractions and their complications, which will lead to a better postoperative outcome compared to general practitioners.
• The study will help in promoting good patient care, preventing some possible complications, and raising the level of confidence in their management.

Materials and Methods

This is a survey-based study. The scope of the study is based on evaluating the young dentists’ level of confidence in performing dental extraction and dealing with related complications, through evaluating their knowledge, attitude, and limitations. This will serve in determining their level of confidence while dealing with different kinds of extraction complications. A validated survey by a Biostatistician and two professors in the Oral and Maxillofacial Surgery department at King Abdulaziz University Dental Hospital in Jeddah was sent to the participants in a google-form to complete the questionnaire. Participants were all general practitioners including postgraduate students, who are currently working in the governmental or private sectors. The selection of the participants was based on inclusion and exclusion criteria.

Inclusion criteria

Any dental postgraduate and general practitioner, who is currently practicing dentistry, in KSA.

Exclusion criteria

Pre-clinical dental students

Study design and area

A cross-sectional, observational study, in Jeddah, SA.

Study subject

The study included dental university, government-owned, and private hospitals/centers. Postgraduate and general practitioners who are now practicing dentistry and performing tooth extractions.

Instruments & interventions

All of the participants completed a fully validated questionnaire that probed them about their confidence in executing the extraction procedure, their attitude toward dealing with difficulties, their methods of prevention of potential complications, and their readiness in dealing with those complications.

Statistical analysis

Collected data were analyzed using SPSS^® version 25, for Windows statistical software. Descriptive statistics (mean and standard deviation), regression, and one-way ANOVA tests were used.

Budget

No external funding was needed during this observational study.

Results and Discussion

During a period of eight months, started on the 10^th of August 2021 until the end of March 2022, the survey of our study included a total of 313 participants; divided into 102 (32.6%) males (n= 102); and (67.4%) females (n= 211) group respectively, most of whom are under the age of 30 years old ( 20-25 68.1% and 26-30 29.4%) and more than half of the study population graduated in the past four years between the year 2016 – 2020 ( 55%). Our results were divided between three groups Governmental hospital setting, private clinics, and University setting groups.

About two-thirds of the participants (191) worked in a University Hospital at the time of data collection. The rest were divided equally between governmental and private centers (62 and 60 respectively).

After running a descriptive analysis on the collected data and doing one-way ANOVA we found that there is a significant correlation between practicing dentistry at the university hospital and age, since more than 90% of the participants practicing dentistry at a University Hospital were between 20 and 25 years with a highly significant p-value of 0.000 (Table 1).

Regarding the duration of practice of dental extraction; university practitioners had statistically significantly fewer years of practice, compared to their colleagues in government and private centers.

It was further found that most of the University Hospitals practitioners graduated from King Abdulaziz University (82%), who actually constitute most workers in all the healthcare sectors.

Regarding the number of surgical teeth extractions performed weekly, more than half of the participants did 1-5 extractions per week. Interestingly, most of those practitioners were working at a University Hospital. This proved that dentists working in a University Hospital setting exhibited higher practice levels compared to those practicing in private and other governmental sectors. However, governmental and private sectors showed six to 10 surgical teeth extractions per week at a rate of 6% and 10% respectively.

When running the same test on simple tooth extractions the percentage of participants doing between one to five extractions per week raised from 50 % to 85%. Most of the participants doing simple tooth extraction were from university hospitals, leading to a significant correlation between working in a University Hospital and having a higher rate of simple tooth extractions.

In nonsurgical tooth extraction, most of the participants (85% n=266) extracted one to five teeth per week, 6.1% extracted six to ten teeth, 2.2% extracted eleven to fifteen, and 1.9% extracted more than fifteen teeth. On the other hand, 4.8% did not practice dental extractions weekly.

Table 1. Descriptive Statistics illustrated

Significant results were encountered in this study which included six questions distributed among the participants; questions number one, three, five, eight, nine, and 13 will be illustrated in the upcoming tables.

Q1: Did you face a root fracture complication during a procedure?

The most common complication that occurred was root fracture during extraction with 190 of the participants (p= 0.00), which was more encountered in a governmental setting, 156 managed the case immediately, while 34 referred their cases (p = 0.000). A total of 123 of the practitioners, did not inform their patients about the occurrence of the complication, and only 33 informed their patients (p = 0.001) (Table 2).

Table 2.  Root fracture complication

Q3: Did you face a complication of luxation or an injury to the neighboring teeth during a procedure?

A total of 45 dentists gave an affirmative answer, most of them were in a university setting, while the rest were equally divided (p = 0.003). 38 dentists managed the case, while the rest referred their patients (p =0.017). Most of the dentists did not inform the patient n=37, while the rest informed them about the complication (p = 0.003) (Table 3).

Table 3.  Luxation or injury to adjacent teeth complication

Q5: Did you face a complication of an alveolar bone fracture during a procedure?

A total of 34 respondents admitted they faced alveolar bone fractures, with the least among them being in private clinics (p = 0.006). 29 managed the case while the rest referred their patients (p = 0.037). 28 dentists informed their patients about the complications, while the remaining dentists did not (p = 0.006) (Table 4).

Table 4.  Alveolar bone fracture complication

Q8: Did you face a complication of dislocating the mandible during a procedure?

A total of 19 participants confirmed the occurrence of this complication (p = 0.0000), most of them referred to the case n=16, and only three managed the case, which was practiced in the university (p = 0.000). Only three informed their patients about their complications (p = 0.000) (Table 5).

Table 5.  Dislocation of the mandible complication

Q9: Did you face a complication of fracturing the maxillary tuberosity during a procedure?

A total of 38 participants answered yes to this question, with the higher response being among the governmental group (p = 0.001). 29 managed the case, and the rest referred their patients (p = 0.002). 27 dentists did not inform their patients and only two informed them about the complication (p = 0.000) (Table 6).

Table 6.  Fracturing the maxillary tuberosity complication

Q13: Did you face a complication of disturbing artificial restorations during a procedure?

Only 6 participants responded with yes to this question, four from the governmental group and two from the university group (p = 0.013). Five managed the case on the same visit, and one referred his patient (p = 0.047). Three dentists did not inform their patients, and the rest informed them about the complication (p = 0.002) (Table 7).

Table 7.  Disturbing artificial restorations complication