Key words:
Deep caries - partial caries removal - stepwise caries removal - total caries removal
INTRODUCTION
Dental practitioners often come across deep carious lesions which if eliminated totally
may lead to pulp exposure.[1] In such situations, the majority of practitioners may choose to perform pulpectomy
as the treatment of choice despite the fact that the pulp can regenerate and the inflammation
can be reversed.[2] Even today, the management of deep caries approximating the pulp is a challenge
for clinicians.[3] Traditionally, the treatment entails a total elimination of carious lesion to stop
the progression of the disease and to provide a stable platform for
the restoration thereafter. However, this trend has been questioned because both the
tooth structure and the pulp could be affected adversely.[4],[5] Other more conservative techniques of caries management have been recommended in
the literature.[6],[7] Removal of deep caries over two visits separated by a period of weeks to months
is a stepwise excavation technique.[6] Incomplete removal of carious dentin and leaving residual caries under the permanent
restoration is known as partial caries removal technique.[7]
The stepwise technique is an efficient way to save and protect the pulp, especially
in cases where caries is very deep.[8] Bjorndal et al. reported that stepwise technique was 12% more successful than the complete elimination
of caries after 1-year of follow-up.[9] On the other hand, the concerns for post-treatment symptoms including pulp exposure
could be allayed by partial removal of caries. The literature shows that incomplete
excavation does not predispose teeth with deep caries to more post-operative complications.[10] In comparing stepwise technique with partial caries removal, the success rates were
99% and 86%, respectively, when cases were followed up to 1.5 years.[11]
The approach toward deep caries management is influenced by the age of dentist, knowledge
about the pathology of caries, and the understanding of the scientific basis of different
techniques.[12] Dentists do not agree on single uniform management because the available evidence
about the effectiveness of different treatments of deep carious lesions is inconsistent.[13] The management preferences for caries removal vary in different parts of the world.[1],[14]
[15]
[16]
[17]
[18] However, data are limited about deep caries management preferences among dentists
from the Middle East. Furthermore, little is known about the influence of gender and
clinical experience of dentists in managing deep carious lesions. This study aimed
to report the management preference of deep caries and evaluate gender and years of
experience differences among dentists in the Eastern province of Saudi Arabia.
MATERIALS AND METHODS
This observational cross-sectional study was conducted in the form of printed self-administered
questionnaire following ethical approval. The dentists from the public and private
dental clinics in the cities of Dammam, Khobar, Dhahran, Qatif, Al Ahsa, and Abqaiq
were approached in person to achieve a higher response rate. The dentists (n = 243) willing to participate in the study were provided with a questionnaire. The
respondents were briefed about the purpose and potential benefits of the study and
their rights as participants. In addition, they were provided with the contact of
researchers for any queries. Implied consent was obtained by filling out the questionnaires.
A questionnaire was developed based on the information from the previous studies.[1],[14]
[15]
[16] The instrument was piloted by distributing it over a group of 25 dentists, and based
on their responses, minor corrections were made to increase the success of the study.[19] The final questionnaire consisted of 17 questions distributed over three sections.
The first section collected participants’ demographic data including age, gender,
level of qualification, and place of work.
The second section consisted of four different clinical scenarios about the absence
or presence of pain/symptoms and the risk of pulp exposure similar to a previous research.[15] The respondents were asked about their opinion to manage deep caries in each situation.
In the first clinical scenario, there was no pain or risk of pulp exposure associated
with deep caries. The second clinical situation presented no pain, but a risk of exposure
was present. The third clinical scenario showed nonspontaneous pain to cold or hot
stimulus but no risk of exposure. The last scenario was about a nonspontaneous provoke
pain with a risk of exposure.
The fourth section included questions about the behavior of dentists toward incomplete
caries removal, diagnostic criteria, and expected success rate of different management
techniques, namely complete caries excavation, stepwise caries excavation, and partial
caries removal.
Statistical analyses were performed using SPSS Version 22.0 (IBM Corp. Armonk, NY,
USA). Frequency distribution was calculated for qualitative variables, and means and
standard deviations were determined for quantitative variables. Chi-square test was
used to compare study responses between gender and years of clinical experience at
a significance level of P < 0.05.
RESULTS
Of 243 dentists, 177 returned the questionnaire giving a satisfactory response rate
of 72.8%. Respondents included 63.3% (n = 112) male and 36.7% (n = 65) female dentists. The majority, i.e., 73.4% (n = 130) worked in the government sector [Table 1]. The participants had an average experience of 9.25 ± 8.43 years in dental practice.
Complete caries excavation was the management of choice by 82.5% (n = 146) when there was no pain and no risk of pulp exposure associated with deep caries
in permanent teeth. The stepwise technique was preferred by 57.8% (n = 102) if there was no pain but a risk of exposure was present. Complete caries removal
was chosen by 55.9% of respondents, in case of nonspontaneous pain associated with
no risk of exposure. The respondents were split between root canal treatment (42.4%)
and stepwise technique (38.4%) if there were nonspontaneous pain and a risk of exposure
[Table 2].
Table 1:
Demographic information of study participants
|
Demographic characteristics
|
n(%)
|
|
Gender
|
|
|
Male
|
112 (63.3)
|
|
Female
|
65 (36.7)
|
|
Place of work
|
|
|
Private clinics
|
42 (23.7)
|
|
Government clinics
|
130 (73.4)
|
|
Both private and public clinics
|
5 (2.8)
|
|
Years in clinical practice
|
|
|
1-5 years
|
86 (48.5)
|
|
6-10 years
|
25 (14.1)
|
|
11-20 years
|
48 (27.1)
|
|
21-30 years
|
18 (10.2)
|
Table 2:
Management preferences of deep caries in different clinical situations
|
Clinical scenarios
|
Complete caries removal, n(%)
|
Partial caries removal, n(%)
|
Root canal treatment, n (%)
|
Stepwise caries removal, n (%)
|
|
1. No risk of exposure, no symptoms
|
146 (82.5)
|
14 (7.9)
|
1 (0.6)
|
16 (9)
|
|
2. Risk of exposure, no pain
|
32 (18.1)
|
32 (18.1)
|
11 (6.2)
|
102 (57.8)
|
|
3. No risk of exposure, nonspontaneous pain
|
99 (55.9)
|
10 (5.6)
|
22 (12.4)
|
46 (26)
|
|
4. Risk of exposure, nonspontaneous pain
|
22 (12.4)
|
12 (6.8)
|
75 (42.4)
|
68 (38.4)
|
About half (47.5%) of the respondents agreed that it was unethical to leave residual
caries under the permanent restorations in deep cavities. However, all respondents
disagreed that complete caries removal was necessary even if the pulp exposure was
expected in deep caries. The pulp exposure (81.4%) was the major concern associated
with complete caries removal technique. Regarding partial caries removal technique,
the progression of caries (73.4%) and treatment failure (58.8%) were the most common
concerns. Approximately 55% of the respondents considered that stepwise caries excavation
technique could increase the risk of postoperative pain [Table 3]. About 81.4% of the dentists believed that high success rate (>80%) was associated
with complete caries removal [Table 4].
Table 3:
Major concerns for dentists about different techniques of caries removal
|
Techniques of caries removal
|
n (%)
|
|
Complete caries removal
|
|
|
Risk of exposure
|
144 (81.4)
|
|
Risk of postoperative pain
|
88 (49.7)
|
|
Risk of treatment failure
|
27 (15.3)
|
|
Risk of progression of caries
|
33 (18.6)
|
|
Longevity of the restoration
|
33 (18.6)
|
|
Partial caries removal
|
|
|
Risk of exposure
|
49 (27.7)
|
|
Risk of postoperative pain
|
83 (46.9)
|
|
Risk of treatment failure
|
104 (58.8)
|
|
Risk of progression of caries
|
130 (73.4)
|
|
Longevity of the restoration
|
34 (19.2)
|
|
Stepwise caries excavation
|
|
|
Risk of exposure
|
54 (30.5)
|
|
Risk of postoperative pain
|
98 (55.4)
|
|
Risk of treatment failure
|
81 (45.8)
|
|
Risk of progression of caries
|
70 (39.5)
|
|
Longevity of the restoration
|
36 (20.3)
|
Table 4:
Dentists’ opinion about the success rate of different techniques of caries removal
|
Techniques of caries removal
|
n (%)
|
|
Complete caries removal
|
|
|
>80%
|
144 (81.4)
|
|
51%-80%
|
31 (17.5)
|
|
20%-50%
|
1 (0.6)
|
|
<20%
|
1 (0.6)
|
|
Partial caries removal
|
|
|
>80%
|
11 (6.2)
|
|
51%-80%
|
35 (19.8)
|
|
20%-50%
|
73 (41.2)
|
|
<20%
|
58 (32.8)
|
|
Stepwise caries excavation
|
|
|
>80%
|
38 (21.5)
|
|
51%-80%
|
95 (53.7)
|
|
20%-50%
|
40 (22.6)
|
|
<20%
|
4 (2.3)
|
The criteria used to assess caries removal in deep lesions are summarized in [Figure 1]. Hardness (85.3%) was the most commonly used criterion followed by the color of
carious dentin (50.3%). No statistically significant differences were found between
male and female respondents regarding the management of deep caries, major concerns
associated with different techniques, and the success rates (P > 0.05). Similarly, the opinion of the dentists with > 10 years of clinical experience
did not significantly differ from the participants with <10 years of experience (P > 0.05).
Figure 1: Criteria to assess caries removal in deep caries
DISCUSSION
This study attempted to report the management preferences of deep caries and evaluate
gender and years of experience differences among dentists in the Eastern province
of Saudi Arabia. The most preferred management for deep asymptomatic caries with no
expected exposure was complete caries excavation by the majority of dentists (82.5%),
and only 9% preferred stepwise caries removal in the present study. The results are
in agreement with a previous study. Weber et al. reported that in Sothern Brazil, most dentists (71.1%) were in favor of complete
caries removal and 17.6% preferred stepwise excavation.[14]
In contrast, a Norwegian study reported that dentists showed an almost equal preference
for complete caries removal (49%) and stepwise caries excavation (45%) techniques
in a similar clinical situation.[15] In the present study, dentists’ preference for complete caries removal technique
could be either due to the limited knowledge about the effectiveness of stepwise caries
excavation[20] or they were unaware of current concepts of minimally invasive dentistry.[21] Recently, a study showed that most dentists in Saudi Arabia had no knowledge or
training of minimally invasive procedures.[22]
Previous studies showed differences in the preferences of dentists for various techniques.
In a survey among German dentists, 50% said that they would remove caries completely
even if pulp exposure was expected.[1] Similarly, Oen et al. reported that 62% of US dentists preferred total caries removal even when there was
a risk of exposure.[16] Another survey reported that German and French dentists preferred complete caries
removal while Norwegian dental professionals frequently used a stepwise technique.[18] In the present study, the risk of exposure dramatically influenced dentists’ decision
as only 8.1%-12.4% opted for complete caries removal when there was a risk of pulp
exposure with or without pain. It can be seen that management preferences differ widely
in different parts of the world, but the risk of pulp exposure appears the most important
variable when dealing with deep carious lesions among dentists in the Eastern province
of Saudi Arabia.
It has been reported that stepwise technique has a significantly better success rate
(74%) than complete caries excavation (62.4%) after 1 year of follow-up.[9] However, patient compliance, an increased cost, and failure of temporary restoration
are drawbacks of this technique.[11] Maltz et al. found that the partial caries removal success rate (99%) was higher than stepwise
technique (86%) after 18 months of follow-up in their multicenter randomized controlled
trial.[11] Nevertheless, partial caries removal was practiced by a small percentage of dentists
in our study which is similar to the results reported by Weber et al.
[14] What mostly concerned the participants (73.4%) was the progression of caries followed
by treatment failure and postoperative pain with partial caries excavation technique.
Moreover, almost half (48%) went further to consider this approach unethical, and
two-thirds expected <50% success rate. There is no evidence that leaving residual
caries renders tooth prone to complications; in fact, incomplete caries removal can
be advantageous.[10]
Lack of valid and reliable diagnostic criteria presents a challenge for clinicians
to decide the extent to which caries should be removed.[1] The hardness of dentin is a general criterion applied to determine the extent of
caries.[17],[18] Most of the dentists in our study also used hardness of affected dentin to assess
the caries excavation. The findings are in agreement with the previous studies.[1],[17]
[18] A recent survey reported that dentists in the US used the hardness as the primary
criterion for caries removal.[17] Similarly, most German, French, and Norwegian dentists used hardness as a criterion
for caries removal.[1],[18]
Years of clinical experience had been associated with the different excavation techniques,
and dental professionals with less than 10 years of experience preferred more conservative
approaches than those with more than 10 years of experience.[14] On the contrary, our study did not find an association between years of clinical
experience and gender with the type of caries removal procedure, and the findings
are in agreement with the results of a previous study.[1]
The questionnaires were distributed among dentists in the major cities of the Eastern
province, and practitioners working in remote areas were not included in the study.
The majority of the respondents were male dentists working in public dental clinics.
Future studies should involve different regions of the country to evaluate trends
in deep caries management at national level and investigate differences in management
preferences by gender (male and female dentists) and type of dental office (private
and public).
Conclusions
The results showed that the majority of dentists preferred complete caries removal
when there was no risk of pulp exposure, and stepwise caries excavation was opted
in case risk of exposure was present. Partial caries removal was the least preferred
technique due to the fear of caries progression.
Dental practitioners need to update themselves and practice minimally invasive approaches
for caries management. Dentistry curriculum and continuing education programs should
focus on teaching conservative techniques to dental students and practitioners.
Financial support and sponsorship
Nil.
