|Year : 2022 | Volume
| Issue : 1 | Page : 17-22
Management preference of deep carious lesion in permanent mature teeth among dentists in Riyadh city
Afra H Elrashid1, Nada A Alsulaiman2, Alanoud M Alqahtani2, Farah M Algholamy3, Abdulaziz M Alobaida2
1 Department of Restorative, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
2 Dental student, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
3 Dental Intern, College of Dentistry, Alfarabi Colleges, Riyadh, Kingdom of Saudi Arabia
|Date of Submission||22-May-2021|
|Date of Decision||16-Aug-2021|
|Date of Acceptance||19-Sep-2021|
|Date of Web Publication||29-Apr-2022|
Dr. Nada A Alsulaiman
3422 Muhammad Bin Al Hajab Street- Al Khuzama, Riyadh 12582
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Introduction: The management of deep caries lesion can be accomplished by complete caries excavation, partial caries removal, and stepwise excavation techniques. Dentists do not agree on a single management due to available evidence about the effectiveness of different treatment options of deep carious lesion that are inconsistent.
Aim: The aim is to investigate the attitude and behavior of management preference of deep caries in mature permanent teeth among dentists in Riyadh city. In addition, to compare these findings with academic standards, World Dental Federation and International Caries Consensus cooperation (ICCC).
Materials and Methods: A randomized cross-sectional study was conducted in which 540 questionnaires were distributed to dentists in Riyadh city. The questionnaire included four clinical scenarios to investigate the participant's attitude and behavior of management preference of deep carious lesion of permanent teeth in Riyadh city in 2019.
Results and Discussion: Response rate was 74%. Findings illustrate that 86.8% of participants preferred complete caries excavation in case of deep caries with no pain nor risk of pulpal exposure. 41.3% of the participants preferred complete caries excavation in case of deep caries with no pain but risk of pulpal exposure presence. 64.8% participants preferred complete caries excavation in case of deep caries with pain on provocation and no risk of pulpal exposure. 58.3% participants preferred root canal treatment in case of deep caries with pain on provocation and with risk of pulpal exposure. About 76.80% of participants believed that after 2 years from complete caries removal, a high success rate (more than 80%) will result.
Conclusion: The majority of participants prefer more invasive approaches in the treatment of deep carious lesions and unaware of the minimally invasive dentistry.
Keywords: Caries removal, carious exposure, complete caries removal, deep caries lesion, dentists, partial caries removal, stepwise caries removal
|How to cite this article:|
Elrashid AH, Alsulaiman NA, Alqahtani AM, Algholamy FM, Alobaida AM. Management preference of deep carious lesion in permanent mature teeth among dentists in Riyadh city. Saudi J Oral Sci 2022;9:17-22
|How to cite this URL:|
Elrashid AH, Alsulaiman NA, Alqahtani AM, Algholamy FM, Alobaida AM. Management preference of deep carious lesion in permanent mature teeth among dentists in Riyadh city. Saudi J Oral Sci [serial online] 2022 [cited 2023 Apr 2];9:17-22. Available from: https://www.saudijos.org/text.asp?2022/9/1/17/344397
| Introduction|| |
Dental caries is one of the most prevalent chronic infectious diseases worldwide. It is a multifactorial oral disease caused primarily by the complex interaction of cariogenic oral flora with fermentable dietary carbohydrates on the tooth surfaces over time. Acid production by the bacteria will lead to demineralization of the organic component dental tissue. The pathological process begins on the outer surfaces of the tooth and may progress to the dentin-pulpal complex, ultimately compromising the vitality of the tooth.
Dentin-pulp complex responses to irritation in different ways according to severity, intensity, and time. Protective mechanism includes initiating sclerotic dentin through the calcification of dentinal tubules or by the formation of reactionary/reparative dentin by pulpal odontoblasts.,,
The European Society of Endodontology defined Deep caries as “Caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp. Practitioners face significant challenges when treating deep carious lesions approaching a healthy pulp. The treatment options of deep caries lesion include complete caries removal, partial caries removal and stepwise caries excavation. Removal of soft dentin till the hard dentin is known as complete caries removal, which is considered as an overtreatment and is no longer recommended., Removal of peripheral soft caries, leaving residual soft carious dentin in pulpal floor under a permanent restoration is known as partial caries removal. Removal of caries carried out in two separated appointments by an interval time of months, to reduce the pulpal exposure and allow the reparative dentin formation is known as stepwise excavation technique. During the first appointment of stepwise excavation technique, the dentist removes the soft dentin and places a temporary restoration for 6–12 months. During the second visit, complete removal of carious dentin is carried out until firm and sound dentin is reached.
Multiple studies investigated the management preference of deep caries lesions, results show that the majority of practitioners practiced invasive techniques.,,,,,,, Complete caries removal was the treatment of choice in the past decades which is not recommended anymore due to its invasiveness. A recent study conducted in the eastern provenance of Saudi Arabia concluded that the majority of dentists preferred using complete caries removal.
A new approach focuses on a conservative less invasive method known as minimally invasive dentistry (MID). Partial caries removal and stepwise excavation techniques are considered a minimal invasive approach to manage the deep caries. These techniques aim to maintain the pulp vitality., Recently, the treatment of deep carious lesions has been shifted to a conservative and less invasive therapy; however, the implementation is limited. A 2016 study reported that Saudi population had minimal knowledge about MID.
Many studies discussed the preferences and attitudes of dentists and dental students about different techniques of caries removal. Dentists do not agree on a single management due to available evidence about the effectiveness of different treatment options of deep carious lesion that are inconsistent.
Therefore, the aim of the present study is to report the attitude and behavior of management preference of deep caries in mature permanent teeth among dentists in Riyadh city. In addition, compare these findings with International Caries Consensus cooperation (ICCC), academic standards and World Dental Federation (FDI).
| Materials and Methods|| |
Ethical approval for the study was obtained from the Institutional Review Board of the private dental university in Riyadh (RC/IRB/2019/138). In this observational cross-sectional study, a structured, close-ended and self-administered questionnaire was distributed in 2019 to a number of dentists (n = 540) working in public and private dental clinics in Riyadh city regarding the management preference of deep caries lesions in permanent mature teeth. The study included participants that were willing to complete the questionnaire.
The anonymous questionnaire consists of 26 multiple choice questions that investigate the basic attitude and behavior related to the treatment modalities of deep caries that were undertaken and validated from the previous study. The developed questionnaire was first evaluated for its credibility and reliability through the performance of a pilot. The pilot study was carried out by selecting a small sample (n = 25) of the dentist; accordingly, some modifications have been made to meet the needs of the study. Random sampling technique was used to list all governmental and private dental clinics in Riyadh city that was obtained from the Ministry of Health statistical yearbook of 2016. Subsequent division was made among the list dividing them in different regions (North, south, east, west and center). A random draw was made to get a small portion out of the entire population. A total of 67 clinics distributed among Riyadh city were chosen randomly. We contacted each dental clinic, and an estimated number of dentists were provided. We distributed 108 questionnaires in each region however we collected 80 questionnaires thus resulting in a sum of 400 questionnaires. Each district and each clinic received hand-delivered questionnaires. The questionnaires were hand-collected on the same day. Informed consent was conducted as well. The sample size was calculated based on a previous study carried out in Riyadh and Al Kharj.
The questionnaire was divided into four sections:
- The first section inquired the participant sociodemographic information which consisted of gender, the number of years in practice and place of work (private or governmental)
- The second section presented different methods of caries detection and excavation and source of information that was used
- The third section consisted of four clinical scenarios regarding the presence or absence of pain and risk of pulpal exposure. The first clinical scenario questioned the management of deep caries with no pain nor risk of pulpal exposure. The second clinical scenario questioned the management of deep caries with no pain, and there is a risk of pulpal exposure. The third clinical scenario questioned the management of deep caries with pain which is stimulated by heat or cold but not spontaneous and no risk of pulpal exposure. The fourth clinical scenario questioned the management of deep caries with pain and a risk of pulpal exposure
- The fourth section assessed the behavior of dentists toward partial caries removal, diagnostic criteria to assess sufficient caries removal, and expected success rate of different management techniques.
Data were analyzed using the Statistical Package for Social Sciences (SPSS, Chicago IL, USA) version 22. Descriptive statistics were used to summarize the data. Categorical variables were expressed as proportions, and continuous variables were expressed as the mean ± standard deviation. The Chi-square and independent t-tests were used to analyze categorical and continuous data, respectively. P < 0.05 was considered statistically significant.
| Results|| |
Out of 540 distributed questionnaires, 400 dentists have answered the questionnaire completely. The response rate was 74%. Participants included 63% (n = 252) males and 37% (n = 148) female dentists. In the present study, results showed that 81.8% (n = 327) of the dentists work in private hospitals, 11.3% (n = 45) in governmental hospitals, and a minority of a total of 7% (n = 28) worked in both. Of the 400 dentists who participated, a mean of 5.90 years of experience was recorded. 27.12 was the mean number of patients treated weakly by the dentists. Majority of the participants 68.5% (n = 274) were general practitioners while 31.5% (n = 126) were specialized in various fields. The participants that graduated between the year of 1973-2010 were 21.3% (n = 85), while 78.8% (n = 315) were graduated between 2010 and 2019. Visual-tactile methods and radiographs were the preferred diagnostic methods to detect caries by a percentage of 48.6% and 48.1%. High-speed handpiece was chosen by 41.6% as the method of caries excavation. [Table 1] summarizes the criterion used to assess sufficient caries removal in deep caries.
[Table 2] details the statistical analysis of the management preference of deep carious lesions in each clinical scenario. In the first clinical scenario, 86.8% preferred complete caries removal. In the second clinical scenario, 41.3% of the participants preferred complete caries removal, and 35.5% preferred stepwise caries excavation. In the third scenario, 64.8% preferred complete caries removal. In the fourth scenario, 58.3% preferred to choose root canal treatment as a treatment of choice.
|Table 2: Management preferences of deep caries in different clinical situations|
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Thirty-seven percent of the participants agreed on the necessity of complete caries removal even if there was a risk of pulpal exposure. However, 27.3% disagreed that leaving residual caries in deep cavity under a permanent restoration is unethical. [Table 3] demonstrates major concerns related to caries management.
The main concern related to selecting complete caries removal was the fear of pulpal exposure. However, the progression of caries was the main concern if stepwise and partial caries excavation technique were performed.
About 76.80% of dentists believed that after 2 years from complete caries removal, a high success rate (more than 80%) will result. 40.30% of dentists thought that after 2 years from stepwise excavation technique the success rate will be between 50% and 80%. 42.30% of dentists thought that after 2 years from partial caries removal the success rate will be between 20% and 50%.
Out of the dentists who were using the stepwise technique, the majority of the participants 40.5% preferred leaving 6 weeks' interval between the first and the second appointment. While only 27.3% preferred leaving a 6 month or more interval time. [Table 3] details the source of information utilized by the dentists to update themselves about deep caries management.
| Discussion|| |
The presented study focused on the management preference of deep caries lesion among dentists in different regions in Riyadh city. According to the results, the majority of dentists in Riyadh city were practicing the conventional invasive techniques. In the first, second, and third clinical scenarios majority of the participants favored to apply complete caries removal. The presented results are in agreement with previous studies conducted.,,,,,
Alnahwi et al. reported that 82.5% preferred complete caries removal. Similarly, a multinational study reported that French and German dentists would prefer complete caries removal in deep caries lesion. While Norwegian dentists would prefer stepwise excavation technique.Moreover, a study conducted in Finland reported that minimally invasive techniques (stepwise or selective caries removal) were preferred (64%) in the case of absence of both pain and risk of exposure.
Bjorndal et al. opted that there is no scientific evidence supporting the progression of residual caries approximating the pulp whenever there is successful sealing. Moreover, Marggraf et al. reported that there was bacterial reduction in sealed caries lesion. These might be some of the reasons behind selecting less invasive excavation methods.
In the presented study, the majority of the participants seek complete caries excavation to avoid caries progression. Fear of restoration failure and cost-effectiveness were additional factors to consider when selecting this approach.Although long-term studies reported that incomplete caries excavation techniques facilitate the longevity of restoration and pulp vitality.,
In comparison among gender, results showed that females were approaching minimal invasive methods apart from males in agreement with Almahdy et al. In contrast, studies showed there was no significant difference among gender regarding the management of deep caries.,
Different criteria are used to assess sufficient caries removal in deep carious lesions. In this study, the majority of the participants selected hardness (80%) as a criterion for the assessment. This result is in agreement with previous studies conducted.,,
Majority of our participants were aware of MID procedures but did not follow them in their daily practice because they did not know how to perform it. Only 27.3% of the participants who were using stepwise excavation technique were aware about the correct time between the first and the second visit (6 months or more). This result indicates that few dentists in Riyadh city have enough knowledge practicing stepwise excavation methods in a proper way. Similarly, a study showed the majority of the participants did not receive sufficient education on minimally invasive techniques. Although they obtained their knowledge through updated textbooks and journals.
Dentists should acquire knowledge and implement them in their daily practice by following evidence-based practice provided by certain academic standards and guidelines that are generally meant to deliver the best treatment in dental practice.
According to the guidelines followed by college of dentistry and dental clinics at the University of Iowa, stepwise caries removal is indicated in deep carious lesion extending into the pulpal third or quarter of the dentin with asymptomatic teeth and without any pulpal complications. Moreover, the Japanese Society of Conservative Dentistry developed an evidence-based clinical Guideline for restoring carious permanent teeth. The treatment of deep caries with high risk of pulpal exposure can be avoided by the use of stepwise excavation. In addition, the FDI recommends that national dental associations, universities and dental schools: “encourage their members to apply evidence-based research results into daily practice, discourage their members from using invasive treatment methods that completely remove carious tissue close to the pulp and support less-invasive and tooth-preserving caries excavation methods as recommended by the ICCC.”,
The FDI and the ICCC support the use of minimally invasive techniques to preserve the vitality of the pulp even if it requires leaving affected soft dentin near the pulp. On the contrary, our results reflect that the majority of participants were approaching invasive treatment modalities for deep carious lesions, which shows that they are unaware of guidelines and standards that support minimally invasive dentistry (MID).
This study has a number of strengths and limitations. In this study, we intentionally increased the sample size to increase the significance level of our findings. In addition, we compared our findings to academic standards and associations. The self-administered questionnaire limited the accessibility to governmental practitioners that may restrain the generalization of the results. In addition, restricted the distribution to Riyadh city, thus excluding other regions in Saudi Arabia.
| Conclusion|| |
After analyzing the results statistically, the study concluded that many participants were not aware of the outcomes that come along with the use of nonselective techniques (stepwise caries techniques and partial caries excavation). As a future recommendation, it is important to use most updated resources and articles with continuous education programs about the minimally invasive methods for deep carious lesions for dentists. Implementation of minimally invasive dentistry to the syllabus of dental bachelor curriculum for dental students. Further study is needed with a larger sample.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369:51-9.
Heymann HO, Swift EJ Jr., Ritter AV. Sturdevant's Art and Science of Operative Dentistry-E-Book. ST. Louis, Missouri. Elsevier Health Sciences; 2014.
National Institute of Health Consensus Development Panel. National Institutes of Health Consensus Development Conference statement. Diagnosis and management of dental caries throughout life, March 26-28, 2001. J Am Dent Assoc 2001;132:1153-61.
Langeland K. Tissue response to dental caries. Endod Dent Traumatol 1987;3:149-71.
Magloire H, Bouvier M, Joffre A. Odontoblast response under carious lesions. Proc Finn Dent Soc 1992;88 Suppl 1:257-74.
Bjørndal L, Darvann T. A light microscopic study of odontoblastic and non-odontoblastic cells involved in tertiary dentinogenesis in well-defined cavitated carious lesions. Caries Res 1999;33:50-60.
European Society of Endodontology (ESE) developed by, Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, et al.
European Society of Endodontology position statement: Management of deep caries and the exposed pulp. Int Endod J 2019;52:923-34.
Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: A critical review. J Am Dent Assoc 2008;139:705-12.
Alnahwi TH, Alhamad M, Majeed A, Nazir MA. Management preferences of deep caries in permanent teeth among dentists in Saudi Arabia. Eur J Dent 2018;12:300-4.
] [Full text]
Schwendicke FW, Innes NP. “2.1.” Management of Dental Emergencies in Children and Adolescents. Hoboken, NJ. Wiley-Blackwell; 2019.
Innes N, Schwendicke F. Treatment options for carious tissue removal. Clin Dent Rev 2019;3:3.
Ricketts D, Kidd E, Innes NP, Clarkson JE. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database of Systematic Reviews. 2006;(4).
Schwendicke F, Stangvaltaite L, Holmgren C, Maltz M, Finet M, Elhennawy K, et al.
Dentists' attitudes and behaviour regarding deep carious lesion management: A multi-national survey. Clin Oral Investig 2017;21:191-8.
Katz CR, de Andrade MD, Lira SS, Vieira EL, Heimer MV. The concepts of minimally invasive dentistry and its impact on clinical practice: A survey with a group of B razilian professionals. Int Dent J 2013;63:85-90.
Crespo-Gallardo I, Hay-Levytska O, Martín-González J, Jiménez-Sánchez MC, Sánchez-Domínguez B, Segura-Egea JJ. Criteria and treatment decisions in the management of deep caries lesions: Is there endodontic overtreatment? J Clin Exp Dent 2018;10:e751-60.
Stangvaltaite L, Kundzina R, Eriksen HM, Kerosuo E. Treatment preferences of deep carious lesions in mature teeth: Questionnaire study among dentists in Northern Norway. Acta Odontol Scand 2013;71:1532-7.
Weber CM, Alves LS, Maltz M. Treatment decisions for deep carious lesions in the public health service in Southern Brazil. J Public Health Dent 2011;71:265-70.
Kakudate N, Yokoyama Y, Sumida F, Matsumoto Y, Gordan VV, Gilbert GH. Dentists' practice patterns of treatment for deep occlusal caries: Findings from a dental practice-based research network. J Dent 2019;84:76-80.
Crespo-Gallardo I, Martín-González J, Jiménez-Sánchez MC, Cabanillas-Balsera 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:e1205-15.
Bjorndal L, Simon S, Tomson PL, Duncan HF. Management of deep caries and the exposed pulp. Int Endod J 2019;52:949-73.
Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Systematic Review. 2013;(3).
Elagra ME, Alzaid HF, Alsabeh MM, Altoub NA, Binhowaimel SF. Caries-related treatment decisions of general dental practitioners in Riyadh, Saudi Arabia. Saudi J Oral Sci 2020;7:174. [Full text]
Shah AH, Sheddi FM, Alharqan MS, Khawja SG, Vohra F, Akram Z, et al.
Knowledge and attitude among general dental practitioners towards minimally invasive dentistry in Riyadh and AlKharj. J Clin Diagn Res 2016;10:C90-4.
Alammari MR. Innovative technology for caries detection and validation histologically to support restorative dentists and researchers' decision-making in vitro
. Saudi J Oral Sc 2017;4:22.
Schwendicke F, Meyer-Lueckel H, Dörfer C, Paris S. Attitudes and behaviour regarding deep dentin caries removal: A survey among German dentists. Caries Res 2013;47:566-73.
Oen KT, Thompson VP, Vena D, Caufield PW, Curro F, Dasanayake A, et al.
Attitudes and expectations of treating deep caries: A PEARL network survey. Gen Dent 2007;55:197-203.
Croft K, Kervanto-Seppälä S, Stangvaltaite L, Kerosuo E. Management of deep carious lesions and pulps exposed during carious tissue removal in adults: A questionnaire study among dentists in Finland. Clin Oral Investig 2019;23:1271-80.
Marggraf T, Ganas P, Paris S, Schwendicke F. Bacterial reduction in sealed caries lesions is strain- and material-specific. Sci Rep 2018;8:3767.
Maltz M, Garcia R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS, et al.
Randomized trial of partial vs. stepwise caries removal: 3-year follow-up. J Dent Res 2012;91:1026-31.
Lima FF, Pascotto RC, Benetti AR. Stepwise excavation in a permanent molar: 17-year follow-up. Oper Dent 2010;35:482-6.
Almahdy A, Alqahtani M, AlShamrani M, AlKathery M. The concepts of minimally invasive dentistry and its impact on clinical practice: A survey with a group of dentists in Saudi Arabia. Int J Med Sci Clin Invest 2017;4:2620-3.
Momoi Y, Hayashi M, Fujitani M, Fukushima M, Imazato S, Kubo S, et al.
Clinical guidelines for treating caries in adults following a minimal intervention policy--Evidence and consensus based report. J Dent 2012;40:95-105.
Innes NP, Frencken JE, Bjørndal L, Maltz M, Maltz M, Ricketts D, et al
. Managing carious lesions: Consensus recommendations on terminology. Adv Dent Res 2016;28:49-57.
[Table 1], [Table 2], [Table 3]