Introduction

The optimal option to restore endodontically treated teeth (ETT) continues to be a controversial topic that is highly debated. Dentine weakening caused by loss of structural integrity, dentine aging, decreased proprioception, and, to a lesser extent, endodontic medicament-induced dentine changes result in overall tooth strength reduction [1-3]. The clinician is left uncertain due to a lack of evidence regarding the best restorative choice and the availability of various restorative materials and techniques for restoring ETT [4].

Traditionally, fabricating crowns supported on posts and cores to restore the function and aesthetic of endodontically treated teeth was routinely performed [5]. A post is a dental restorative material inserted into the root of a badly affected tooth to offer additional retention and support in the retention of the core build-up [6]. Despite clinical success with the use of intraarticular posts, the main disadvantage remains in this system, which is the additional removal of sound tissue for fitting the post into the canal [7] and the overall effect on the biomechanical behavior of the restored teeth [8]. According to recent in vitro experiments, the use of posts did not affect the fatigue resistance of posterior teeth, nor in anterior teeth with ferrule [9, 10].

Microleakages are reduced, and the remaining tooth structure is preserved and protected, which leads to improved survival of teeth treated endodontically with adequate coronal cuspal coverage. Immediate placement of an excellent coronal restoration has been shown to reduce microleakage, and, as a result, the risk of endodontic treatment failure is reduced. In contrast, cuspal coverage and preservation of the remaining coronal tooth structure have improved fracture resistance of endodontically treated teeth [11].

In minimally invasive dentistry, precision is essential. Magnification and accurate rotating instrumentation provide the operator with the visual accuracy and delicate preparation abilities required to preserve good dental tissue while only removing decaying tissue [12]. A less invasive approach preserves and conserves the tooth structure and is superior in maintaining the balance between mechanical, biological, functional, and aesthetic of treating ETT without using intraarticular posts and performing total crown restoration instead, using the pulp chamber as a retentive resource, as in case of endocrowns [13].

Endocrown is a porcelain fixed crown to a nonvital posterior tooth anchored to the internal portion of the pulp chamber and the margins of the cavity, thus obtaining both macro mechanical retention by pulp walls and micro retention by using adhesive cement [9]. Endocrown is indicated for teeth with badly damaged clinical crowns, little inter-occlusal clearance, and short, divergent roots [14]. Many factors influence the performance of endocrown, including the type of material used, the loading axis, and the design of the preparation. Along with its biomechanical features, lithium disilicate glass-ceramic (LDS) is the most commonly used material for endocrown restorations [15].

The way post-endodontic restorative therapy is administered does not entirely follow the recommendations of the literature but is instead impacted by geographic area, age, and specialty. These data show that each dentist develops their therapeutic philosophy based on experience. Thus, surveys are essential for evaluating and comprehending treatment options in post-endodontic restorations. Hence this survey-based research aims to assess the indirect restorative treatment plan decision-making of endodontically treated teeth made by dental practitioners, as well as their knowledge and perceptions of the available treatment alternatives.

Materials and Methods

Study design

It was a descriptive cross-sectional study conducted among a sample of dental practitioners in Saudi Arabia.

Sample size calculation

A minimum sample of 377 study participants was calculated based on an acceptable margin of error of 5%, a confidence level of 95%, a population of dentists of 16887 [16], and a response distribution of 50%. A convenient sampling methodology was employed to select the sample. However, to improve the power of the study, a sample of (N=425) participants was considered.

Study instrument

A thorough review of the literature was carried out, considering relevant publications. The questionnaire items were then extracted from the study conducted by Shetty et al. and others [17-19]. The subject experts were consulted to establish the face validity of the questionnaire. Based on the experts' suggestions, changes were made to the questionnaire. A pilot study was then carried out on a sample of ten dental practitioners working in the restorative dentistry department. The reliability of the questionnaire instrument was tested using Chronbach's coefficient alpha (0.711). These ten survey responses were excluded from the final analysis.

Questionnaire content

The questionnaire comprised nine items on socio-demographic and practice-related information (gender, age, country of graduation, practice area, primary workplace, qualifications, and the number of patients treated per week), and the remaining items assessed knowledge, attitude, and confidence of dental practitioners towards various restorative options for endodontically treated teeth.

Questionnaire administration

Both an electronic version and a manual paper-based questionnaire were developed and administered to the study participants. A survey monkey platform was utilized to prepare the electronic version of the questionnaire, and the link was shared on dental practitioners' social media platforms such as Twitter, Telegram, Instagram, and WhatsApp. Similarly, a paper-based questionnaire was distributed to the dental practitioner who did not answer the questionnaire link shared on social media.

Data collected using electronic and manual methods were compiled in an excel sheet and then transferred to the statistical program for analysis. A structured, close-ended, and self-administered questionnaire, moreover an option was offered for further comments at the end of relevant questions, was distributed to the study participants. Moreover, a   cover letter was included to explain the aims of the study, how the data would be used, and the voluntary and anonymous nature of study participation.

Statistical analysis

Data were analyzed using IBM-SPSS version 25 (Armonk, NY: USA). Descriptive statistics of frequency distribution and percentages were calculated for the categorical variables. The Chi-square test was applied to assess the association between the characteristics of the study participants and questionnaire items. A value of p<0.05 was considered significant for all statical tests.

Results  and Discussion

A total of 425 responses were collected and analyzed. Most research participants (54.1%) were males aged 25 to 40 (49.4%). Many subjects graduated from Saudi Arabia (91.1%) and practiced in the central region (48.9%). The students/interns (38.1%) constituted the bulk of the study participants. Most of the subjects had less than five years of experience. The characteristics of the study participants are shown in (Table 1).

Table 1. Characteristics of the study participants (N=425)

When enquired about the reason for restoring posterior endodontically treated teeth, more than half (51.8%) agreed to reinforce the tooth. Almost 58.4% of the participants agree that the amount of remaining tooth structure is the criteria for restoring posterior endodontically treated teeth. The study participants commonly used post, core, and crown to restore the posterior endodontically treated tooth. Nearly half (49.40%) agreed that the most common type of post that is used for restoring posterior endodontically treated teeth was prefabricated fiber post. Almost 60.2% of study participants agreed to place a post after every endodontic treatment, while 77.40% mentioned placing a post is a cost-effective option. Contrarily, 74.40% of the study subjects changed treatment options due to payment concerns (Figure 1). Cast post and core are more technique sensitive and more difficult. Nearly 61.9% are not confident in doing endocrowns, and 69% did not attend any workshops on it. 31.8% reported that they got familiar with endocrowns through social media (Table 2).

Table 2. Knowledge of the treatment options for restoring endodontically treated tooth

The reasons for restoring endodontically treated teeth and the available options for treatment are shown in Table 3. The reason for restoring endodontically treated teeth showed significant association with age (p<0.001), graduation country (p<0.001), practice area (p=0.001), dental practitioner type (p<0.001), duration of qualification as a dentist (p<0.001) and the number of patients seen per week (p<0.001). Similarly, the treatment option of restoring endodontically treated teeth showed a significant association with place of practice (p=0.021) and the number of patients seen per week (p=0.044).

Table 3. Reasons and treatment options for restoring endodontically treated tooth

A statistically significant association was found between the age (p<0.001), practice place (p=0.014), and Dental practitioner type (p=0.019) with conservative treatment of endodontically treated teeth. Similarly perceived cost of the endodontically treated tooth differed significantly across various practice areas (p=0.017), dental practitioner type(p=0.044), duration of qualification as a dentist (p=0.018), and the number of patients seen per week (p=0.010), as shown in Table 4.

Table 4. Association between characteristics of the study participants and conservative and costly treatment of endodontically treated tooth

The technique sensitivity in restoring endodontically treated teeth and confidence in restoring endodontically treated teeth are shown in Table 5. The participant's age (p=0.038), dental practitioner type (p=0.035), and the number of patients seen per week (p=0.021) were associated with significant technique sensitivity in the restoration of endodontically treated teeth. However, restoration of the endodontically treated tooth did not show any significant association with the characteristics of the study participants.

Table 5. Association between characteristics of the study participants and questionnaire items