Non-Clinical Factors Inuencing Clinical Decision of Root Canal Treatment (RCT): A Survey of Patients Reasons for Avoiding RCT

Root canal treatment (RCT) has high success rate, still many patients are apprehensive of this procedure. Objective: To determine the frequency of patients' avoiding RCT in endodontically treatable teeth and identify the reasons given by the patients to avoid RCT. Methods: This cross-sectional study was conducted at the department of operative dentistry at Margalla Institute of Health Sciences, Rawalpindi including patients who refused RCT in endodontically treatable teeth (n= 250). Patient's demographics, tooth related variables and reason for not pursuing root canal treatment were recorded. Descriptive statistics and Chi-Square test were run to report sample characteristics with level of signi�cance at ≤ 0.05. Results: Two hundred and �fty (250, 21.09%) out of 1185 patients advised for RCT refused the procedure. Majority of the participants were female (169, 67.6%). The mean age of the patients was 32.66 years (SD ± 12.313). The most common reason as reported by almost half of the patients (106, 43%) for avoiding RCT was “�nancial constraints” followed by a desire to take a “second opinion or advice” (46,18%). The majority of the male participants as compared to female participants refused RCT due to �nancial constraints with statistically signi�cant association (p ˂ 0.001). A reasonable number of female patients also identi�ed “want second opinion/advice” as a reason for avoiding RCT(p ˂ 0.001). Conclusions: The frequency of patients avoiding RCT in endodontically treatable teeth was 21.09%. Financial constraints followed by seeking a second opinion or advice were the most common reasons identi�ed by the patients avoiding RCT in endodontically treatable teeth.

One of the objective of Root Canal Treatment (RCT) is to preserve the natural dentition when affected by pulpal or periapical pathosis through debridement of necrotic and vital pulp tissue followed by obturation of root canal with clinically acceptable material [1,2]. RCT not only prevents severance of periodontal bers that help in proprioception but also aid in the retention of tooth that might have extracted [3]. The reported success rate of RCT is around 86-98% according to observational studies [3,4]. A recent meta-analysis also estimated RCT success rate to be 92.6% under 'loose criteria ' and 82.0% under 'strict' criteria [5]. Despites these high gures many patients are apprehensive of the Root Canal Treatment. A study conducted in Chettinal Dental College, India for ve years concluded that "patient's misbelief that RCT will fail" was the major reason for avoidance of RCT [6]. Another questionnaire based survey on insight of patient's perception regarding root canal treatment showed that the "lack of awareness about RCT procedure" was the reason of avoidance of RCT and preference of extraction [3]. "Fear and anxiety" are also reported as major factors that result in avoidance of RCT and other dental treatments [7][8][9][10].
Although there are scarcity of the literature on this topic, still the existing studies recognized the fact that there is a need to create awareness among patients regarding RCT [9,10]. In our clinical practice we have also observed a

I N T R O D U C T I O N
number of patients avoiding root canal treatment in teeth with either pulpal or periapical pathosis despite the fact that teeth have good restorability and prognosis. The rationale of this study was to address patients' apprehension and negative perception regarding root canal treatment by identifying the factors that result in the avoidance of root canal treatment. The objective of this study was to determine the frequency of patients' avoiding root canal treatment in endodontically treatable teeth. The secondary objective was to identify the reasons given by patients to avoid root canal treatment.

R E S U L T S
Copyright © 2022. PJHS, Published by Crosslinks International Publishers Ethical approval was taken from Institutional Ethical Review Committee (ERC Ref No: DB/173/22). This crosssectional, observational study was conducted at the department of operative dentistry in a teaching institution at Margalla Institute of Health Sciences, Rawalpindi. Sample size was determined with the help of a study conducted by Bansal and Jain in which 16% of patients preferred extraction over RCT [3]. With known population proportion of 16%, con dence level of 95% and margin of error of 5%, population size or sample turned out to be minimum of 207. Non probability, convenience sampling technique was used. The inclusion criteria was patients 18 years or above in age, refusing to undergo RCT in teeth with adequate restorative and periodontal status, in which a clinical decision of root canal treatment was made, irrespective of the clinical diagnosis. However, the patients having cognitive impairment and open apex who refuse to undergo RCT treatment were excluded. Once identi ed the information was collected by one of the authors in a Performa containing closed ended questions regarding patient's demographics (age, gender, and education), tooth related variables (tooth number, pain intensity, pulpal diagnosis, periapical diagnosis) and reason for not pursing root canal treatment. The researcher choose a reason as identi ed by the patient. SPSS version 16.0 was used for data analysis. Descriptive statistics (mean and standard deviation for age and frequencies with percentages for demographics variables, tooth related variable and patient's reasons for refusing RCT) were run to report sample characteristics. An association between demographic (and tooth related) variables and reasons for refusing RCT was made using Chi-Square Test (Fisher exact test where cell count was less than 5). Level of signi cance was kept at less than or equal to 0.05 The present study was an attempt to get an insight of the patients' reasons for avoiding RCT. Although there is literature regarding patients' perception of RCT, but to our limited knowledge there is scarcity of the literature on the patients' reasons for avoiding RCT [5,6,10]. Most common reason as identi ed by the present study is " nancial constraints". Financial status of the patient is an important DOI: https://doi.org/10.54393/pjhs.v3i06.340

Patients' Reasons For Avoiding Root Canal Treatment (RCT)
Male (81) Female (169) Most common factor or reason as reported by almost half of the patients (106, 43%) for avoiding RCT was " nancial constraints". The second most common reason identi ed in this research was a desire to take "second opinion or advice" before undergoing RCT which was chosen by 46 (18%) patients. Figure I shows Figure 1: Non-Clinical Factors as reported by patients for avoiding Root Canal Treatment nancial constraints with statistically signi cant association (p<0.001). Reasonable number of female patients (44, 26.03%), however, also identi ed the reason "want second opinion/advice" before RCT. As compare to other age groups, almost half of the patients belonging to age groups 29-39 and 40-50 years {(32, 47.76%) and (21, 45.65) respectively} identi ed " nancial constraint" as a reason for refusing RCT with statistically signi cant association. A statistically signi cant association was also seen between pain intensity and reason for avoiding RCT. Majority of the patient with moderate pain (51.8%) identi ed " nancial constraints" as a reason for avoiding RCT. Majority of the patients (18, 48.64%) experiencing no pain preferred to get a second opinion/advice before RCT procedure (p<0.001  (67) 40-50 (46) 50 and above (21) Illiterate (44) Matric orintermediate (164) Graduate (41) No pain (37) Mild (46) Moderate (83) Severe/worst (84) 47 (  Farid H et al., Non-Clinical Factors In uencing Clinical Decision of RCT barriers identi ed in this survey were all related to nancial reasons like "could not afford the cost," "insurance did not cover procedures," and "did not want to spend the money". Non -nancial barriers like "afraid of dental treatment" and "busy routine" were less cited reasons. However, our result is in contrast to Sadasiva et al., study conducted in India where "cost" was the fourth most common reason for avoidance of the RCT and perception that RCT is a failure treatment was the most common reason for avoidance of RCT [6]. In our study previous bad experience of self or others was third most common reason for avoiding RCT. Extracting the tooth and replacing it with prosthesis weather xed or removable was an expensive option with patients sometimes not aware of the cost of the replacement prosthesis. Proper counselling and explaining the importance of natural tooth. Sayed et al., studied that cost of the future treatment may help in scenarios where patient is preferring a replacement prosthesis instead of RCT of clinically salvageable teeth [15]. The second most common reason identi ed in this study was "wants second opinion/advice". Twenty six (26 %) percent female identi ed this factor as a reason for avoiding RCT whereas only 2% of male patients identi ed this reason. In developing countries socio-cultural structure and nancial dependency limits women's' decision making power regarding their own health and lives [16]. This may be a possible reason for female identifying "wants second opinion/advice" before agreeing for RCT. In National Health and Nutritional Examination Survey (NHANES) conducted in 2013-2014 and 2015-2016 a similar reason identi ed for not seeking dental care was "another dentist recommend not doing the procedure" [17]. This survey however recorded the information regarding not seeking dental care in general and not speci c to RCT. Secondly no discrimination of the respondents reasons according to gender was made. Least cited yet thought-provoking reason identi ed in our study was "preference of implant over RCT". Although only 7% of the patients identi ed this reason but extraction and placement of implant instead of RCT in a tooth with adequate restorative and periodontal status is a great concern. Parirokh et al., many patients and dentists think that implant may offer better results and this trend is increasing among both dentists and patients [17,18]. Till date, not a single non-biased evidence based study has shown that extraction and placement of implant is preferential over RCT [19,20]. Although the present study probes the reasons of patients not seeking RCT in endodontically treatable teeth. Still data collection from a single center was a limitation of this study.
C O N C L U S I O N S treatable teeth was 21.09%. Financial constraints followed by seeking second opinion or advice were the most common reasons identi ed in this study by the patients avoiding RCT in endodontically treatable teeth.
The author(s) received no nancial support for the research, authorship and/or publication of this article.