Dentists knowledge, attitudes and determining factors of the conservative approach in teeth with reversible pulpitis and deep caries lesions

J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1205 Journal section: Operative Dentistry and Endodontics Publication Types: Research Dentist´s knowledge, attitudes and determining factors of the conservative approach in teeth with reversible pulpitis and deep caries lesions Isabel Crespo-Gallardo, Jenifer Martín-González, María C. Jiménez-Sánchez, Daniel Cabanillas-Balsera, Benito Sánchez-Domínguez, Juan J. Segura-Egea Endodontics Section, Department of Stomatology, (Conservative Dentistry Section), University of Sevilla, Spain Correspondence: Department of Stomatology School of Dentistry University of Sevilla C/ Avicena s/n 41009-Sevilla Spain [email protected] Received: 30/10/2018 Accepted: 22/11/2018 Abstract Background: The aim of this study was to investigate dentists` knowledge, attitudes and factors regarding the conservative approach in the management of deep caries lesions (DCLs) in teeth with reversible pulpitis. Material and Methods: 187 dentists were contacted directly or by mail, and 125 (67%) were finally included in the study. Dentists were requested to answer an open/discursive questionnaire about the routine approach to the diagnosis and treatment of DCLs, including knowledge-related attitudinal items. Results: Total caries excavation was the preferred treatment option for more than 80% of dentists in case of DCL with reversible pulpitis. Only a small percentage (8%) chose partial caries removal, leaving some carious dentin close to the pulp to avoid pulp exposure. More than a half (51%) of respondents considered that cariogenic microorganisms must be removed or caries would progress. Dentists teaching at the University strongly disagreed with this statement (OR = 4.6; 95% C.I. = 1.3 – 15.8; p = 0.017). Good clinical result was the most chosen reason (83%) to choose a specific treatment. Patient’s oral health (84%) and patient’s age (70%) were the two patient-related factors most taken into account for the choice of treatment. Conclusions: Total caries excavation is still the most frequently chosen treatment in teeth with DCL and reversible pulpitis. The joint assessment of the answers given by respondents allows to conclude that the new knowledge and concepts about caries lesions and the more conservative approach to DCLs have not still been incorporated by dentists into their usual clinical practice. Key words: Caries, deep caries lesions, dental pulp capping, dental pulp health, dentists, endodontic therapy, reversible pulpitis, treatment decisions. doi:10.4317/jced.55395 http://dx.doi.org/10.4317/jced.55395 Article Number: 55395 http://www.medicinaoral.com/odo/indice.htm © Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488 eMail: [email protected] Indexed in: Pubmed Pubmed Central® (PMC) Scopus DOI® System Crespo-Gallardo I, Martín-González J, Jiménez-Sánchez MC, Cabanillas-Bal- sera D, Sánchez-Domínguez B, Segura-Egea JJ. Dentist´s knowledge, attitudes and determining factors of the conservative approach in teeth with reversible pulpitis and deep caries lesions. J Clin Exp Dent. 2018;10(12):e1205-15. http://www.medicinaoral.com/odo/volumenes/v10i12/jcedv10i12p1205.pdf J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1206 Introduction The conception of caries as an infectious disease meant that, until the end of the last century, the surgical treatment of the caries lesion consisted in the elimination of all the infected biomass, with replacement of the lost hard tissue. The new concept of caries as an ecological imbalance in the oral biofilm (1), and not as an infection, has led to a change in the approach to the treatment of caries lesions. Currently, the preservation of dental hard tissues, by mean of minimally invasive restorative treatments, takes precedence over their elimination (2). In the treatment of teeth with asymptomatic vital pulps and carious lesions involving, radiographically, the inner pulpal third of dentin (deep carious lesion, DCLs), the main objective should be to avoid pulp exposure, allowing tooth retention for long-term, and avoiding potentially painful, costly, and invasive endodontic treatments (3). An important part of the clinical practice of dentists is to treat deep carious lesions (DCLs). Several studies have demonstrated that the diagnostic criteria and the therapeutic protocols applied by each dentist in the management of DCLs lesions are variable (4). The depth that is reached in the removal of carious dentin is especially variable, ranging from the non-selective removal of decayed tissue to hard dentin, with complete excavation of the decayed tissue, leaving only hard dentin, with high risk of pulp exposure, to selective caries removal, leaving soft dentin in the area of the cavity near the pulp (5,6). The International Caries Consensus Collaboration Group (ICCC), linked to the European Organization for Caries Research, the International Association for Dental Research-Cariology Group and the American Dental Education Association-Cariology Section, has established well-defined criteria for the treatment of DCLs (7, 8). These criteria considered complete excavation or removal of carious dentin over-treatment DCLs (3,4,7-9). However, several surveys carried out in different countries indicate that some dentists continue this practice (5,6,10,11). In Spain, as long as we know, no study has been published providing current data on the management of DCLs by dentists. Therefore, it is not known if dentists have incorporated minimally invasive approaches to the removal of decayed tissue in their usual clinical practice. The aim of this study was to conduct a survey investigating dentists` knowledge, attitudes and factors regarding the conservative approach to deep caries lesions in teeth with reversible pulpitis. Material and Methods Ethical approval of this study was considered unnecessary by the Ethical Committee of the University of Sevilla. -Selection and recruitment process The survey was carried out in Sevilla (Andalucía, Spain) during 2017. A total of 187 dentists, randomly selected amongst those working or attending postgraduate courses in the Dental School of the University of Sevilla, with both private and public clinical practice, were contacted directly or by mail. One hundred and thirty four (71.6%) fulfilled the survey, being excluded 6 dentists because they answered the questionnaire incompletely and 3 dentists because they were no longer practicing clinical activities. Therefore, 125 (66.8%) dentists were included in the study. The purpose of the study was explained to all and indicated confidential and anonymous processing of the data. -Questionnaire Respondent dentists were requested to answer an open/ discursive questionnaire based in previous surveys conducted in Brazil (12), USA (5) and Europe (6,10,11) (Table 1, 1 continue, 1 continue-1). Translation of the English master versions was performed by native speakers. After several questions concerning the respondents’ demographic, educational, and professional backgrounds, presented the respondents the same 3 clinical scenarios originally developed by Weber et al. (12) and also used by Koopaeei et al. (5) (Fig. 1). The simulated clinical cases were composed of young patients (ages 25, 11, and 14 for cases A,B, and C, respectively) with no medical history of allergies or use of medications, reporting the occurrence of pain provoked by chewing or by cold in posterior teeth as their main complaint (12). Each case included a clinical occlusal view, a periapical radiograph, and a clinical occlusal view after opening the lesion, plus information about the patient’s age, general and dental history, oral hygiene practices, and the reasons for the consultation and clinical radiographic examination. For each case, the respondents had to choose the most likely diagnosis, and then which treatment would be indicated. Respondents were also asked concerning routine approaches to treating DCLs (5), developed originally by Schwendicke et al. (10), and questions concerning the respondents’ reasons for their treatment preferences and knowledge-related attitudinal items (5), developed originally by Schwendicke et al. (10) and Stangvaltaite et al. (11). -Statistical analysis A database was created for further analysis using Excel (Microsoft Corp., Redmond, WA, USA). Data description was carried out by frequency tables to provide an overview of the responses. When obtaining the numerical representation by percentages, the total number of answers for each query was taken into account. Logistic regression analysis was carried out transforming qualitative explanatory variables into binary variables. Explanatory variables were entered and then removed stepwise if p > 0.10 (hierarchical method). Odds ratios (OR) and confidence intervals (CI) were calculated as effect estimates. Significant differences were considered when p < 0.05. J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1207 Thank you very much for taking the time to respond to this the survey about diagnostic and treatment strategies when you encounter a patient with deep carious lesion. This survey is completely anonymous and only takes about 5-7 minutes of your time. Fill in the selected circle or mark it with an X 1. Are you male or female? Male Female 2. In which year did you get your dental degree? Graduate in Medicine and specialist in Dentistry: year _______ Graduate in Dentistry: year_______ 3. Did you get your dental degree from a dental school in Spain or outside of Spain? In Spain, In what school of dentistry did you graduate?__________________ Outside of Spain, in which country did you receive it? ___________, In what School of D entistry did you graduate?_____________ 4. Do you have additional degrees? Yes No If yes, in which dental specialty is your additional degree? Dental specialty 1:__________ In which year did you get this degree:__________ Dental Specialty 2:__________ In which year did you get this degree:__________ 5. In which of the following settings do you work? (Select all that apply) Private practice Public Health Dentistry Salaried activity, specify below Academic, specify department below Other, specify below I do not have a clinical practice as a dentist. 6. How many years have you been practicing? General Practice__________ years Specialty 1 __________: __________ years Specialty 2 __________: __________years 7. During the last 5 years have you attended any continuing education courses in the field o Cariology? Yes No 8. During the past 5 years have you read any articles about Minimum Intervention (e.g., caries removal) in Cariology? Yes No 9a. Based on Case 1, what is the most likely diagnosis? (Select all that apply) Healthy pulp Reversible pulpitis Irreversible pulpitis Pulp necrosis 9b. Based on Case 1, what would be your indicated treatment: Total caries excavation in 1 step Total caries excavation in 2 steps Partial caries excavation Pulpotomy Root canal treatment 10a. Based on Case 2, what is the most likely diagnosis? Healthy pulp Reversible pulpitis Irreversible pulpitis Table 1: Questionnaire. J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1208 Pulp necrosis 10b . Based on Case 2, what would be your indicated treatment Total caries excavation in 1 step Total caries excavation in 2 steps Partial caries excavation Pulpotomy Root canal treatment 11a. Based on Case 3, what is the most likely diagnosis? Healthy pulp Reversible pulpitis Irreversible pulpitis Pulp necrosis 11b. Based on Case 3, what would be your indicated treatment Total caries excavation in 1 step Total caries excavation in 2 steps Partial caries excavation Pulpotomy Root canal treatment 12. With reference to an asymptomatic vital tooth with a deep carious lesion on 20 years old female patient how would you proceed? Perform total caries removal; if there is a small pulpal exposure, perform a direct pulp cap Perform total caries removal; if there is a small pulpal exposure, perform root canal treatment Perform caries removal in 2 steps (stepwise excavation); if there is a risk of pulp exposure, leave some carious dentin close to the pulp and then finish the caries removal a few weeks or months later Perform partial caries removal; if there is a risk of pulp exposure, leave some carious dentin close to the pulp and perform a permanent restoration Other, specify If your answer to question 12 is "Perform caries removal in 2 steps (stepwise excavation); if there is a risk of pulp exposure, leave some carious dentin close to the pulp and then finish the caries removal a few weeks or months later" a) Then what time frame would you choose? Select one below: 2 weeks to 3 months After 3 to 6 months More than 6 months b) Then what filling material would you use between 2 appointments? Select one below: Cavit Glass Inomer Amalgam filling Composite IRM 13. What are the main reasons for choosing a particular treatment option for your patients with deep caries lesions? (Select all that apply) Ease of use, familiarity with the technique Good clinical results Proven efficacy Recommended by colleague Recommended by clinical research Recommended in text books Profitability Other, please specify  Table 1 continue: Questionnaire. J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1209 Table 1 continue-1: Questionnaire. 14. What are the main factors upon which you base your treatment choice? (Select all that apply) Patient’s general health Patient’s age Patient’s oral health Patient’s attitude and preferences Type of tooth (Anterior, Premolar, Molar) Further restoration needs of the tooth Duration of the total treatment Other, please specify 15. How do you rate the following statements? Strongly disagree Disagree No opinion Agree Strongly agree A. Cariogenic microorganisms must be removed or the carious lesion will progress under a restoration B. A certain amount of microorganisms can be left under the restoration because the carious lesion will not progress if it is sealed C. The carious lesion must be removed completely because it presents a danger to the vitality of the pulp. D. In the case of a deep carious lesion, dental tissue close to pulp must be preserved to avoid any pulp exposure. Thank you very much for participating in this study. Please share with us any other thoughts you have about the survey below. Results -Participants’ characteristics The survey was answered by 125 dentists, 34 men (27.2%) and 91 women (72.8%) (Table 2). Of these, 73 (58.4%) had undergone specialized dental training. The average time of dental clinical practice was 7.1 years. The majority of the respondents worked in private practice (74.4%), and 45.6% had attended at least one continuing education course in cariology in the last 5 years. Ninety-seven (77.6%) had read an article about minimal intervention in the treatment of carious lesions. -Pulpal diagnoses and treatment options Case 1 The answers to the 3 clinical cases are showed in figure 1. Regarding the pulpal diagnosis (Fig. 2, top), in case 1 reversible pulpitis was the most frequent diagnosis (87.1%). Total caries excavation was selected as the best treatment option by 83.8% of dentists, being one-step total caries excavation the modality most frequently chosen (60.2%) (Fig. 2, bottom). Case 2 In case 2, 72.8% of respondents agreed on a diagnosis of reversible pulpitis, and 25.6% considered that the pulp was healthy. Concerning the treatment, 87.9% selected total caries excavation as the best option, choosing onestep and two-step 71.0% and 16.9%, respectively. Case 3 In case 3, 69.7% of dentists chose reversible pulpitis as the diagnosis, and 19.7% agreed on irreversible pulpitis as a possible diagnosis. Most of respondents (63.4%) chose any of the types of total caries excavation, and more than a quarter of dentists (26.8%) indicated that it would perform in this case root canal treatment. Very few dentists (less than 2%) selected pulpotomy as a treatment option. Approximately 8% of respondents in each of the 3 cases chose partial caries excavation as treatment option, being this option significantly more chosen by dentists who received courses in cariology in the last 5 years (OR = 3.1; 95% C.I. = 1.0 – 9.3; p = 0.047). -Asymptomatic vital tooth with a DCL Regarding the clinical situation raised in item 12 of questionnaire (an asymptomatic vital tooth with a DCL on 20 years old female patient) (Fig. 3), 60.8% of dentists chose to perform total caries removal and, if pulpal exposure occur, 46.4% and 14.4% would perform direct pulp capping or root canal treatment, respectively. Less than a third (28.8%) chose to perform caries removal in 2 steps (stepwise excavation) and, if there is a risk of pulp exposure, leave some carious dentin close to the pulp, and then finish the caries removal a few weeks or months later. Only 8.8% of respondents chose to per- J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1210  Fig. 1: Overview of the information included in the 3 cases provided (Koopaeei et al. 2017) (5). J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1211  Fig. 2: Pulpal diagnoses and treatment options selected by respondents for the 3 clinical case scenarios provided in the survey. Variable Value Gender Male 34 (27.2) Female 91 (72.8) Graduation year 2010 (1983-2017) Years of practice 7.1 (0.5 – 35) Dental education country Spain 119 (95.2) Other 6 (4.8) Clinical practice Private 93 (74.4) Public 32 (25.6) Academia Yes 24 (19.2) No 101 (80.8) Specialized training Endodontics 15 (12.0) Periodontics/Implantology 18 (14.4) Oral surgery 11 (8.8) Prosthodontics 11 (8.8) Orthodontics 10 (8.0) Course on cariology in the last 5 years Yes 57 (45.6) No 68 (54.4) Read article on MIC in the last 5 years Yes 97 (77.6) No 28 (22.4) Table 2: Demographic, academic and professional variables. MIC: minimal intervention in cariology form partial caries removal and, if there is a risk of pulp exposure, leave some carious dentin close to the pulp and perform a permanent restoration. This last option was again significantly more chosen by dentists who received courses in cariology in the last 5 years (OR = 5.1; 95% C.I. = 1.0 – 25.8; p = 0.046). -Knowledge and attitude on the management of deep carious lesions Four assertions were included in the questionnaire regarding knowledge and aptitude on the management of deep carious lesions for which the respondents had to indicate agreement or disagreement on a 5-point scale (Table 3). When asked if cariogenic microorganisms must be removed or caries would progress, 50.4% strongly agreed, and only 14.6% and 8.9% disagreed or strongly disagreed, respectively. The dentists who taught at the University strongly disagreed with this statement (OR = 4.6; 95% C.I. = 1.3 – 15.8; p = 0.017). To the question if a certain amount of microorganisms could be left during caries removal, the answers were much divided, and only 15.5% and 14.6% agreed or strongly agreed, respectively. Dentists teaching at the University significantly agreed with this statement (OR = 4.5; 95% C.I. = 1.2 – 16.8; p = 0.0247). J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1212  Fig. 3: Treatment options selected by respondents for the case of an asymptomatic vital tooth with a DCL on 20 years old female patient. DPC: total caries removal and, if pulpal exposure occur, direct pulp capping; RCT: total caries removal and, if pulpal exposure occur, root canal treatment. SWE: stepwise excavation; PCR: partial caries removal. Responses (%) Statement Sdi Dis Nop Agr Sag Cariogenic microorganisms must be removed or the carious lesion 8.9 14.6 11.4 14.6 50.4 will progress under a restoration. A certain amount of microorganisms can be left under the restoration because the carious lesion will not 30.1 17.1 22.8 15.5 14.6 progress if it is sealed. The carious lesion must be removed completely because it presents a 17.9 12.2 26.1 17.1 26.8 danger to the vitality of the pulp. In the case of a deep carious lesion, dental tissue close to pulp must be 14.6 12.2 34.2 17.9 21.1 preserved to avoid any pulp exposure. Table 3: Knowledge-related attitudinal responses to management of deep carious lesions. Sdi: strongly disagree; Dis: disagree; Nop: no opinion; Agr: agree; Sag: strongly agree. NA: not applicable When asked if a carious lesion must be removed to prevent its presence from damaging the vitality of the pulp, again the answers were very distributed, being the most frequent strongly agree (26.8%). The fourth question asked if, treating a deep carious lesion, dental tissue close to the pulp must be preserved to avoid any pulp exposure, and again the opinions of the respondents were very variables, being “no opinion” the most frequent (34.2%). -Factors influencing the treatment choice Finally, dentists were asked about their reasons to choose a specific treatment and about the factors influencing the treatment choice in managing deep carious lesions (Table 4). The good clinical result was the most chosen reason (82.3%), and patient’s oral health (84.0%) and patient’s age (69.6%) were the two patient-related factors most taken into account for the choice of treatment. Discussion This study aimed to investigate dentists` knowledge, attitudes and decisions strategies in the management of DCLs. If the answers given by dentists are assessed globally, it can be concluded that dentists have not completely incorporated into their usual clinical practice the new therapeutic approach to caries lesions, which is more conservative and based on minimal intervention. Total caries excavation is the preferred treatment option in case of DCL with reversible pulpitis. Moreover, the results suggest that there is an excess indication of endodontic treatment. Surveys are a valid method widely used to assess the knowledge, attitudes and decision strategies of dentists (5,10,13). Several surveys conducted in other countries have investigated dentist´s knowledge, attitudes and decisions strategies regarding DCLs, most of them including the same three clinical cases used in the present study and/or similar questions (5,6,10-12). The study sample was selected among general dental practitioner in Andalusia (southern Spain). Both the sample size and the response rate were comparable to those found in other surveys conducted previously (5,10,11). Seventy three per cent of the respondents were women, in agreement with the highest proportion of women who current- J Clin Exp Dent. 2018;10(12):e1205-15. Spanish dentists and deep caries lesions e1213 Variable Value Gender Male 34 (27.2) Female 91 (72.8) Graduation year 2010 (1983-2017) Years of practice 7.1 (0.5 – 35) Dental education country Spain 119 (95.2) Other 6 (4.8) Clinical practice Private 93 (74.4) Public 32 (25.6) Academia Yes 24 (19.2) No 101 (80.8) Specialized training Endodontics 15 (12.0) Periodontics/Implantology 18 (14.4) Oral surgery 11 (8.8) Prosthodontics 11 (8.8) Orthodontics 10 (8.0) Course on cariology in the last 5 years Yes 57 (45.6) No 68 (54.4) Read article on MIC in the last 5 years Yes 97 (77.6) No 28 (22.4) Table 4: Percentage of yes responses for reasons for preferred treatment and main factor for treatment choice in managing deep carious lesions. ly graduate in Spanish dental schools. In other surveys conducted in Spain and other countries, a similar feminization of samples has been observed (12,14,15). The dentists had to answer several questions related to three clinical cases. The first and second clinical scenarios referred to asymptomatic patients with moderately DCLs not reaching the inner third of the dentin, being mostly diagnosed by respondents as reversible pulpitis. Concerning the treatment, total caries excavation (1 step or 2 steps) was the preferred options for more than 80% of dentists. Only a small percentage chose partial caries removal (8%) or RCT (5%). The same two clinical scenarios were used in previous surveys conducted in USA (5) and Brazil (12), being the percentages of answers, in both cases, similar to those of the present study, and preferring most of the respondents remove all the carious tissue. The third case referred to an asymptomatic patient with a DCL and no lingering pain to cold test, showing the radiograph a great radiolucent area into the tooth crown. Seventy percent of dentists diagnosed reversible pulpitis, but 20% chose irreversible pulpitis, being total caries excavation (63%), RCT (27%) and partial caries excavation (8%) the treatments options. In the same case, 35% of American dentists (5) and 7% of Brazilians (12) chose endodontic therapy. It was observed that dentists who received courses in cariology in the last 5 years were three times more likely (OR = 3.1; p = 0.047) to indicate a conservative treatment such as partial caries excavation, highlighting the importance of dental continuing education. Only 8.8% of respondents chose to perform partial caries removal and, if there is a risk of pulp exposure, leave some carious dentin close to the pulp and perform a permanent restoration. This last option was again significantly more chosen by dentists who received courses in cariology in the last 5 years (OR = 5.1; 95% C.I. = 1.0 – 25.8; p = 0.046). The same can be seen in the case of the asymptomatic vital tooth with a deep carious lesion on 20 years old female patient (item number 12); again the dentists who had followed training in cariology in the last 5 years selected more frequently to perform partial caries removal (OR = 5.1; 95% C.I. = 1.0 – 25.8; p = 0.046). This finding agrees with the results of Koopaeei et al. (5), who found that dentists stating more frequently reading articles and attending continuing education courses about minimally invasive treatments and cariology were more likely to