Conservation of natural tooth structure remains a cornerstone goal of modern dentistry. Compared with extraction, endodontics has several advantages such as preservation of masticatory function, maintenance of occlusal stability, improved aesthetics and prevention of alveolar bone loss [9-12]. Moreover, endodontically treated teeth have exhibited good survival rates in long-term studies and provided that these teeth have received an adequate coronal restoration after treatment [9-12]. Consequently, root canal treatment is widely regarded as the preferred treatment option for teeth with irreversible pulpitis and apical periodontitis when restoration is clinically feasible [7,10,11].

Despite the advances made in modern endodontic therapy, misconceptions regarding root canal treatment (RCT) remain common among the general population. Many patients continue to associate RCT with pain, prolonged treatment duration, and high cost, which may discourage them from seeking treatment and, in some cases, lead them to choose tooth extraction instead of preserving the natural tooth [2,3,7]. Fear of pain is one of the most frequently reported reasons for avoiding endodontic treatment. However, previous studies have shown that patients often perceive root canal treatment to be more painful than it actually is, and their experiences following treatment are generally better than anticipated [8-17]. These findings suggest that misconceptions and inadequate understanding play an important role in treatment-related decisions.

Knowledge and awareness are important factors influencing oral health behavior and acceptance of dental treatment. Individuals who understand the purpose, benefits, and expected outcomes of RCT are more likely to seek timely care and opt for tooth-preserving procedures [1,4,5]. In contrast, limited knowledge may result in delayed treatment, self-medication, and progression of dental disease. Previous studies have reported that patient awareness is influenced by several factors, including educational level, socioeconomic status, previous dental experiences, cultural beliefs, and access to oral health information [13-16].

With the widespread use of the internet and social media, patients now have access to a large amount of health-related information. While these platforms can increase public awareness, they may also contribute to the spread of inaccurate information regarding dental procedures. As a result, many patients form opinions about root canal treatment before consulting a dentist. Previous research has shown that patients' perceptions are influenced by information obtained from family members, friends, social media, and healthcare professionals [1,4,13-15]. Understanding these perceptions is important for improving patient education and facilitating informed treatment decisions.

Dental anxiety is another factor that affects attitudes toward root canal treatment. Anxiety related to anticipated pain has been associated with delayed dental visits and avoidance of necessary treatment [17-19]. Studies have demonstrated that individuals with higher levels of dental anxiety are more likely to report negative perceptions of endodontic procedures and increased pain during treatment [18,19]. Appropriate patient counseling and reassurance by dental professionals can help reduce anxiety and improve treatment acceptance [17].

Several studies conducted in different countries have evaluated patients' knowledge, awareness, and attitudes regarding root canal treatment and have reported considerable variation among populations [1,13-16]. A recent study conducted in Turkiye found that educational status and previous treatment experience significantly influenced patients' understanding of endodontic procedures [1]. Similarly, studies from South Asia and the Middle East have reported persistent misconceptions regarding the pain, duration, and cost of root canal treatment despite increasing levels of public awareness [14-16]. These findings indicate that patient perceptions are influenced by social, cultural, and economic factors.

In Pakistan, oral diseases remain a major public health concern, and delayed utilization of dental services is frequently observed. Although a few studies have investigated patient awareness of root canal treatment, misconceptions and inadequate knowledge continue to be reported among the Pakistani population [3,6]. Furthermore, increasing access to online health information and changing healthcare-seeking patterns highlight the need for updated data regarding public perceptions of endodontic treatment. Evaluating patients' knowledge, awareness, and attitudes is essential for identifying existing gaps and developing effective educational strategies.

Therefore, this study was conducted to assess the knowledge, awareness, and attitudes of dental patients toward root canal treatment in Pakistan and to identify factors influencing their treatment preferences. The findings may help guide patient education initiatives and support efforts aimed at improving acceptance of tooth-preserving treatment options.

Study Design and Setting

A descriptive cross-sectional survey was conducted to assess the knowledge, awareness, and attitudes of dental patients toward root canal treatment (RCT) in Pakistan. The study was carried out among patients attending the private dental clinics between January 2026 and June 2026.

Ethical Considerations

The study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants before data collection. Participation was voluntary, and confidentiality of the collected information was maintained throughout the study.

Sample Size Calculation

The sample size was calculated using Cochran's formula for cross-sectional studies:

n = Z²P (1−P)/d²

Assuming a confidence level of 95% (Z = 1.96), an anticipated prevalence of 50% due to the absence of reliable local estimates, and a margin of error of 5%, the minimum required sample size was calculated to be 384 participants. To compensate for incomplete responses and potential non-response bias, the sample size was increased by approximately 15%, resulting in a final target sample of 450 participants.

Study Population

The study population comprised adult dental patients visiting participating dental healthcare facilities during the study period.

Inclusion Criteria

• Patients aged 18 years and above.
• Patients attending dental outpatient clinics during the study period.
• Patients able to understand and respond to the questionnaire.
• Patients willing to provide informed consent.

Exclusion Criteria

• Dental professionals and dental students.
• Patients with cognitive impairment or communication difficulties.
• Patients unwilling to participate.
• Incomplete questionnaires with more than 20% missing responses.

Sampling Technique

A non-probability convenience sampling technique was employed. Eligible participants were approached during their visit to the dental clinics and invited to participate in the study. Individuals who fulfilled the inclusion criteria and provided informed consent were enrolled until the required sample size was achieved.

Pilot Testing and Validation

Prior to the main study, the questionnaire was pilot-tested on 30 participants who were not included in the final analysis. Feedback regarding clarity, comprehension, and relevance was obtained and necessary modifications were made.

Content validity was assessed by a panel of experts in endodontics and dental public health. Internal consistency of the questionnaire was evaluated using Cronbach's alpha coefficient, with a value of ≥0.70 considered acceptable.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA).

Descriptive statistics were used to summarize the data. Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation.

Associations between demographic variables and participants' knowledge, awareness, and attitude scores were assessed using the Chi-square test or Fisher's exact test where appropriate. Independent t-test and one-way analysis of variance (ANOVA) were used to compare mean scores between groups. A p-value of less than 0.05 was considered statistically significant.

Demographic Characteristics

A total of 450 participants completed the questionnaire. Among them, 242 (53.8%) were females and 208 (46.2%) were males. The mean age of the participants was 33.9 ± 11.8 years.

Regarding education, 58 (12.9%) participants had no formal education, 94 (20.9%) had primary education, 136 (30.2%) had secondary education, 118 (26.2%) were undergraduates, and 44 (9.8%) had postgraduate education.

Previous experience of root canal treatment was reported by 167 (37.1%) participants, while 283 (62.9%) had never undergone RCT.

Table 1: Sociodemographic Characteristics of Participants (N = 450).

Table 2: Knowledge Regarding Root Canal Treatment (N = 450).

Awareness Regarding Root Canal Treatment

Dentists were the primary source of information for 184 (40.9%) participants, followed by family and friends 126 (28.0%), social media 74 (16.4%), internet websites 42 (9.3%), and television/radio 24 (5.3%).

Only 171 (38.0%) participants correctly identified that root canal treatment commonly requires two to three visits.

A total of 324 (72.0%) believed that RCT is more expensive than extraction.

Only 248 (55.1%) knew that root canal treatment helps preserve natural teeth.

Awareness regarding the high success rate of modern RCT was reported by only 187 (41.6%) participants.

The mean awareness score was 2.1 ± 1.1 out of 4.

Awareness levels were categorized as:

• Low awareness: 149 (33.1%)
• Moderate awareness: 208 (46.2%)
• High awareness: 93 (20.7%)

      Table 3: Awareness Regarding Root Canal Treatment (N = 450).

Attitude toward Root Canal Treatment

When asked whether root canal treatment is painful:

• Strongly agree: 74 (16.4%)
• Agree: 152 (33.8%)
• Neutral: 96 (21.3%)
• Disagree: 92 (20.4%)
• Strongly disagree: 36 (8.0%)

Overall, 226 (50.2%) participants believed that RCT is painful.

When advised by a dentist to undergo RCT:

• 287 (63.8%) expressed willingness to accept treatment.
• 96 (21.3%) were uncertain.
• 67 (14.9%) were unwilling.

Regarding treatment preference:

• Root canal treatment: 263 (58.4%)
• Tooth extraction: 187 (41.6%)

A total of 344 (76.4%) participants preferred treatment by an endodontic specialist.

Table 4: Attitudes toward Root Canal Treatment (N = 450).

Association between Education and Knowledge

Participants with undergraduate and postgraduate education demonstrated significantly higher knowledge scores than those with primary or secondary education (p < 0.001).

Table 5: Association between Education Level and Knowledge Score.

Chi-square test showed a statistically significant association between educational status and knowledge level (p < 0.001).

Association between Previous RCT Experience and Attitude

Participants who had previously undergone root canal treatment exhibited significantly more positive attitudes toward RCT and were less likely to perceive the procedure as painful compared with participants who had never undergone RCT (p = 0.002).

Gender Differences

No statistically significant association was observed between gender and overall knowledge score (p = 0.218).

This study evaluated the knowledge, awareness, and attitudes of Pakistani dental patients toward root canal treatment (RCT). Although most participants had heard about RCT, important gaps in knowledge and awareness were identified. Misconceptions regarding pain, treatment outcomes, and post-treatment restoration were common, while educational level and previous treatment experience significantly influenced patients' understanding and attitudes.

Approximately three-quarters of the participants were aware of root canal treatment. Similar levels of awareness have been reported in studies from Pakistan, Saudi Arabia, and other developing countries, suggesting that information regarding RCT is becoming increasingly available to the public [2,3,14]. However, awareness does not necessarily translate into accurate knowledge. In the present study, only 62.0% of participants correctly identified the primary purpose of RCT, and just over half knew that the procedure is performed when the pulp becomes infected. Comparable findings have been reported in studies conducted in Türkiye, Saudi Arabia, and Nigeria, where deficiencies in patient understanding of endodontic treatment were also observed [1,14,16]. These shortcomings may be related to limited oral health literacy and dependence on informal sources of information.

Knowledge regarding post-endodontic restoration was particularly poor. Less than half of the participants were aware that a crown is often required following root canal treatment. This finding is clinically important because the long-term survival of endodontically treated teeth depends not only on successful canal therapy but also on adequate coronal restoration. Previous studies have consistently demonstrated higher survival rates for teeth restored with appropriate full-coverage restorations compared with those left unrestored or inadequately restored [10,11]. The low level of awareness observed in this study highlights the need for better patient education regarding the complete treatment process.

Misconceptions surrounding extraction and tooth preservation were also evident. A considerable proportion of participants perceived extraction as a simpler solution than root canal treatment. Similar observations have been reported in previous studies, where treatment cost, fear of pain, and inadequate understanding of treatment outcomes influenced patients' preference for extraction [7]. In Pakistan, financial constraints and limited access to affordable dental care may further contribute to this perception.

Dentists were the main source of information regarding RCT, followed by family members and friends. This finding supports previous reports indicating that dental professionals remain the most influential source of oral health information for patients [1,13,14]. Nevertheless, the growing contribution of social media and internet-based platforms cannot be ignored. While these sources increase access to information, they may also expose patients to inaccurate or misleading content, which can reinforce existing misconceptions about dental treatment.

Fear of pain remained one of the strongest factors influencing patient attitudes. Approximately half of the participants considered root canal treatment to be painful. Similar findings have been reported by Pak and White and by Perkovic et al., who identified pain-related anxiety as a major barrier to treatment acceptance [8,17]. Notably, participants who had previously undergone RCT demonstrated more favorable attitudes and less fear than those without prior experience. This supports earlier research showing that anticipated pain is often greater than the pain actually experienced during treatment [8,17-20].

Although most participants preferred root canal treatment over extraction, the proportion favoring extraction remained substantial. This finding is likely influenced by socioeconomic factors, particularly treatment cost. Previous studies have likewise reported that financial limitations, treatment duration, and anxiety contribute to decisions favoring extraction rather than tooth preservation [7,16]. These factors remain especially relevant in developing countries where out-of-pocket healthcare expenditure is common.

Educational status showed a significant association with knowledge levels. Participants with higher educational attainment demonstrated better understanding of root canal treatment and its benefits. Similar associations have been reported in studies conducted in Pakistan, Türkiye, and Saudi Arabia [1,3,14]. Individuals with greater educational exposure may have better access to health information and a greater ability to evaluate treatment options, resulting in more informed healthcare decisions.

An encouraging finding was the high preference for treatment by an endodontic specialist. This may reflect growing public confidence in specialist dental care and increasing awareness of the benefits of expert management of complex endodontic procedures. Similar trends have been reported in previous studies evaluating patient preferences for dental care providers [1,13].

The findings of this study have important implications for oral health promotion in Pakistan. Misconceptions regarding pain, treatment outcomes, and restorative requirements continue to influence patient decision-making and may contribute to unnecessary tooth loss. Educational initiatives directed toward populations with lower literacy levels, together with effective chairside counseling by dentists, could improve public understanding of endodontic treatment. Furthermore, the use of social media platforms to disseminate accurate and evidence-based oral health information may help counteract misinformation and improve treatment acceptance.

Several limitations should be considered when interpreting these findings. The cross-sectional design prevents the establishment of causal relationships, while convenience sampling may limit the generalizability of the results. In addition, the study relied on self-reported responses, which are susceptible to recall and response bias. Despite these limitations, the relatively large sample size and inclusion of participants from diverse educational backgrounds provide valuable insight into current perceptions of root canal treatment among Pakistani dental patients.

In conclusion, awareness of root canal treatment was relatively high among the study participants; however, significant deficiencies in knowledge and persistent misconceptions were identified. Strengthening patient education and improving access to reliable oral health information may enhance acceptance of endodontic treatment and support the preservation of natural dentition.

The findings of this study indicate that while awareness of root canal treatment was relatively common among Pakistani dental patients, important deficiencies in knowledge and understanding persist. Misconceptions regarding pain, post-treatment restoration, and the advantages of preserving natural teeth were evident among many participants. Higher educational attainment and previous experience with root canal treatment were associated with better knowledge and more positive perceptions of the procedure.

Despite advances in endodontic care, fear of pain and preference for extraction remain significant barriers to treatment acceptance. These concerns may discourage patients from choosing tooth-preserving treatment options and contribute to unnecessary tooth loss.

Improving public understanding of root canal treatment should be a priority. Dentists can play an important role through effective communication and patient counseling, while community-based awareness programs and reliable oral health information delivered through digital platforms may help address misconceptions. Such efforts may encourage informed decision-making and promote the preservation of natural dentition within the Pakistani population.

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