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Restorative treatment decisions for deep proximal carious lesions in primary molars.

Abstract

Aim: To assess clinicians' individual variables that might influence decision-making for the restoration of deep proximal carious lesions in primary molars. Methods: A pre-coded questionnaire that sought participants' treatment choices for a deeply carious second mandibular primary molar as depicted in a simulated periapical radiograph, along with a specific clinical scenario, was distributed among a random sample of 157 dentists and 15 paediatric dentists. Participants were asked to answer all questions. After combining the pulpotomy and pulpectomy treatment choices under a "pulp therapy" category, a binary dependant variable was constructed. Logistic regression of the ratio of the participants who would restore the questioned tooth by the methods in question, was run. Results: A total of 155 dentists (116 males and 39 females) completed the survey, giving a response rate of 90 %. Of these 53 % of dentists recommended pulpotomy followed by definitive restoration and 39% recommended removal of caries and restoration without pulp therapy. In the logistic regression model, males and graduates from English language undergraduate dental programs had higher probabilities of restoring without prior pulp therapy (P<0.03 and P<0.02, respectively). Compared with graduates of Asian dental programs, dentists who graduated from Eastern Europe and the Middle East showed lower like-lihoods of restoring the tooth without prior pulp therapy (P<0.01 and P<0.004, respectively). Dentists who treated an average of 6-16 child patients during a week had a lower probability of restoring the tooth without prior pulp therapy than those who were not currently involved in treating children (P<0.01). No other measured variables were associated with the participant's treatment choices. Conclusions: The lack of agreement among dentists regarding their optimal treatment recommendations for deep proximal carious lesions appears to be due mainly to inter-individual, educational training and practice characteristics factors.

Key words: Restoration, Primary Molars, Proximal Caries, Pulp Therapy, Decision-making

Introduction

Clinical practice guidelines have been defined as "systematically developed statements to assist practitioners and patients in arriving at decisions on appropriate health care for specific clinical circumstances" [Field and Lohr, 1990]. It is important that such decisions be supported by the best available scientific evidence in order to maximize the potential for successful patient care outcomes [Forrest and Miller, 2002].

In this regard, dentists' restorative treatment decision-making merits attention because restorative care accounts for a large proportion of the services they provide [Bader and Kaplan, 1983]. For example, it has been shown that dentists identify caries through a process of pattern recognition that, in most instances, is inextricably linked to the interventional decisions they make. Thus, individual dentists have inventories of caries scripts that, when matched by a particular clinical presentation, lead to their decisions to treat. The scripts comprise salient factors that are dependent upon the individual dentist's personal characteristics and biases, and thus vary substantially from one dentist to the next [Bader and Shugars, 1997].

In paediatric dentistry, there have been a number of clinical studies examining different approaches to the restoration of deep proximal carious lesions in primary molars. Yet there remains a lack of consensus among paediatric dentists on the indications for restorative procedures that are appropriate for the clinical variations that may be encountered. Whereas the United Kingdom (UK) national clinical guidelines in paediatric dentistry state that "Primary molars with loss of more than two-thirds of the marginal ridge usually require a pulpotomy" [Llewelyn, 2000], the American Academy of Pediatric Dentistry (AAPD) recommends indirect pulp treatment, without removal of the deepest carious dentine so as to avoid a pulp exposure, if the tooth has no or reversible pulpitis [American Academy of Pediatric Dentistry, 2006]. Nevertheless, an investigation of the teaching of class II restorations in primary molars among 68 North American dental schools showed diversity in teaching that may reflect uncertainty related to requirements for optimal restorations of such teeth [Guelmann et al., 2001].

A number of dentist, patient and treatment system factors can account for variability in decision making [Kay and Locker, 1996]. Dentist factors include biases, and personal and practice-related characteristics, and, of the personal characteristics, skills/diligence, age/experience, knowledge, and tolerance for uncertainty have been mentioned [Bader and Shugars, 1997]. Specifically, differences in dentists' educational background [Marinho and Richards, 2001], and differing levels of work experience [Omar et al., 2003], could be influential in the process.

In Kuwait, dentists from a number of countries work in the dental healthcare service. This offers the possibility to investigate the association, if any, between educational background and a dentist's clinical decision making. This study sought to evaluate decision criteria and characteristics of dentists practicing in Kuwait that might influence their decisions in the restoration of deep proximal carious lesions in primary molars. In so doing, it was not the purpose to derive an optimal treatment recommendation for the scenarios presented to participants, but rather to explore the treatment variations that may exist and their possible associations with a number of individual-related factors.

Material and Methods

A pre-coded survey form was distributed among a random sample (using a computer software) of 157 dentists of the membership of the Kuwait Dental Association, proportionally representing all six of the governorates that make up the State of Kuwait. In addition, all 15 paediatric dentists practicing in Kuwait were invited to participate in the study. Participants were met in person by one of the investigators, who, after explaining the nature and aim of the study, handed them the anonymous, self-administered questionnaire and instructed them to answer all questions. Completed surveys were later collected at a mutually agreed time.

The questionnaire included the following independent variables: 1. Social variables (age and gender), 2. Educational variables (country of undergraduate education, language of teaching of the undergraduate program, specialty in dentistry, and country of postgraduate education), and 3. Current practice characteristics: (work place, area of practice and average number of children treated per week). The focus of the survey was a simulated periapical radiograph of a deeply carious second mandibular primary molar (Figure 1), along with the following statement: "A healthy 7 year-old child presents to your clinic for his/her first dental appointment. After taking a routine radiographic survey of the teeth, you observe a deep class II mesial lesion on the second mandibular primary molar. The tooth is symptomless and the child has class I molar and incisor relationships with no dental crowding in the upper or lower arches. The child is cooperative and the cost of the treatment should not be considered a factor". Participants were asked to evaluate the radiograph and chose from a list of options their optimal treatment recommendation for that tooth (Table 1).

[FIGURE 1 OMITTED]

Survey validation. The design of the questionnaire was revised several times following discussion among the research group, and was field tested. It was finalized following piloting on a group of 10 general and specialist dentists, who were not included in the reported study.

Statistical Analysis. Data were tabulated, entered into an Excel spread sheet and were analyzed using the Statistical Package for Social Sciences (SPSS, version 13.0). Descriptive statistics were calculated for all study variables. After eliminating the data for 3 dentists who recommended no treatment or extraction, and combining pulpotomy and pulpectomy responses as a "pulp therapy" category, a binary dependant variable was constructed with those dentists recommending pulp therapy followed by a definitive restoration set as 0, and restoration only without pulp therapy set as 1. The model run was by logistic regression of the ratio of the participants who would restore the tooth in question by the treatment categories defined. For all categorical independent variables, dummy variables were calculated in the model. Model fit was assessed by classification plots, outlier analysis, improvement of the 2 log likelihood (2LL) statistic, and by residual plots.

Results

A total of 155 dentists (116 males and 39 females) completed the survey, giving a response rate of 90 %. The mean age of participants was 38.5 years (range: 24-63 years, SD=9.2). Table 1 presents the responses of dentists regarding their recommendation for the treatment of deep proximal carious lesion affecting the primary molar. There were 53% of dentists who recommended pulpotomy followed by definitive restoration and 39% recommended removal of caries and restoration without pulp therapy.

Characteristics of participants who chose to restore the tooth with and without pulp therapy (91 and 61 dentists, respectively) are presented in Table 2. Most female dentists (76%), dentists with a North American or Western European dental education (78% and 77%, respectively), paediatric dentists (87%), and dentists who treated on average more than 16 children per week (82%) recommended pulp therapy prior to restoration. In the logistic regression model, gender, country of undergraduate dental education, language of undergraduate education, and average number of children treated per week were all significantly related to the choice to restore the tooth without or with pulp therapy (Table 3). Males had a higher probability of restoring the tooth without pulp therapy than females (P<0.03).

Those dentists whose teaching language for their undergraduate dental education was English had a higher probability of restoring the tooth without pulp therapy (P<0.02). In comparison to graduates of Asian dental programs, dentists who graduated from Eastern Europe and from the Middle East showed a slightly lower probabilities of restoring the tooth without pulp therapy (P<0.01 and P<0.004, respectively). Dentists who treated an average of 6-16 child patients during a week showed lower probabilities of restoring the tooth without pulp therapy than those who were not currently involved in treating children (P<0.01).

Discussion

For deep proximal carious lesions of primary molars there is a lack of conformity between clinical symptoms and histopathologic findings [Hobson, 1970; Duggal et al., 2002]. Histologically it has been shown that most primary molars have inflammation involving the pulp horn adjacent to a proximal carious lesion, even when caries involved less than half the marginal ridge; and restorations carried out without pulp therapy where proximal caries had manifested clinically with the involvement of the marginal ridge, were suggested by the authors as likely to fail [Duggal et al., 2002; Duggal and Day, 2005].

Elsewhere it has anecdotally been suggested that pulp therapy is necessary when a radiograph shows a carious lesion extending more than halfway through the dentine [Carrotte, 2005]. On the other hand, retrospective chart audits have reported clinical and radiographic success rates of indirect pulp treatment for primary teeth that had deep carious lesions but without signs or symptoms of pulp degeneration, to be higher than 93%, compared 70-74% for formocresol pulpotomy of control teeth [Farooq et al., 2002; Vij et al., 2004]. These authors concluded that indirect pulp treatment is a successful technique and should be considered as an alternative for formocresol pulpotomy in deeply carious primary molars. However, a recent Cochrane review concluded that the options of indirect pulp capping, direct pulp capping, extraction and no treatment, for the treatment of extensive decay in primary molars has not been adequately investigated [Nadin et al., 2003]. How this seeming uncertainty as regards a standard of care for the carious primary molar impacts on clinical decision-making is not clear.

However, the widely-recognized view that clinical decision-making among dentists shows wide variation might reasonably be expected to apply to the clinical case scenario presented in this study. Variations in the operative treatment recommendations of approximal caries affecting permanent molars have been demonstrated among dentists [Mejare et al., 1999; Tveit et al., 1999]. For deep proximal carious lesions of symptomless primary molars, 99% of paediatric dentists and 96% of general dentists surveyed in the USA recommended pulp therapy followed by a restoration, with less than 2% of the paediatric dentists and 4% of the general dentists recommending restoration with amalgam, composite resin or preformed metal crown without prior pulp therapy [McKnight-Hanes et al., 1991]. In the present survey of what constitutes a probably more educationally-diverse group, 59% of the participants reported that they would recommend pulp therapy followed by a definitive restoration and 39% reported that they would restore the tooth without pulp therapy.

When consideration is given to the extent of disagreement among dentists found in this study, it is easy to criticize dentists for failing to achieve greater agreement on optimal treatment recommendations for restoring deep proximal carious lesions of primary molars. However, in the absence of clearly-defined, internationally-accepted, and evidence-based criteria for optimal treatment of deep proximal carious lesions in primary molars, the level of agreement found may represent a reasonable performance, especially given the wide variation in participating dentists' backgrounds.

Some studies conducted in other areas of dentistry have suggested that dental practitioners' personal variables, such as gender and age, do not have a significant effect on their clinical decision-making [Aryanpur et al., 2000]. However, a recent study conducted in Saudi Arabia demonstrated a gender difference in clinical decision-making for endodontic re-treatment [Al-Ali et al., 2005]. This is in agreement with the results of this survey, in which female dentists showed a greater probability to recommend pulp therapy than males. Nevertheless, it should be noted that the size of the female group within the sample was small compared with males.

A "specialization" influence on treatment decision-making for endodontic re-treatment recommendations for permanent teeth was noted in an earlier study [Aryanpur et al., 2000]. In the current work, no such difference was demonstrated, and a possible explanation is that the average number of children treated by general dental practitioners during a week was comparable to the average number of children treated by paediatric dentists.

This study showed that country of undergraduate dental education has a statistically significant effect on the optimal treatment recommendation made. The finding is in agreement with results from previous studies [Aryanpur et al., 2000; Al-Ali et al., 2005]. As previously suggested, an explanation could be that dentists from different universities studied different curricula, and hence different clinical guidelines and protocols. Differences in qualities of clinical training at different dental institutions may offer another possible explanation.

Dentists who treated an average of 6-16 children per week were more likely to recommend pulp therapy than those who were not currently involved in treating children. One possibility is that dentists who do not treat children on a regular basis may have less knowledge and less interest in up-to-date clinical guidelines and research in paediatric dentistry.

Dentists from dental institutions with English language undergraduate curricula were more likely to recommend restoration without pulp therapy. A possible reason is lack of access to clinical guidelines and the existing controversy regarding histological and clinical evidence on the restoration of the deep carious lesion of primary molars, information of which is predominantly published in English language journals. Reports in the medical literature have suggested that, as a result of the poor quality of Russian-language medical journals, and the inability to gain access to the knowledge available in Western medical literature, Russian medical practice has not kept up with the rapid evolution of evidence-based practice [Tillinghast, 1998].

A clear limitation of this study is that clinical decision-making based on a simulated periapical radiograph does not reflect the respondent's actual decision-making process but rather his/her stated recommendation. While this may have the advantage of eliminating potential cues that the participant may pick up in a 'live' presentation, it has the advantage of controlling for precisely those background variables, even if some 'artificiality' is so introduced. What neither the live nor the simulated approach can avoid, however, is the likelihood that what people say they do in a situation and what they actually do can be quite different [Helminen et al., 2002]. Clearly, this study cannot claim to have clarified this last point.

Furthermore, clinical decision-making is a multifactorial process and a simulated radiograph case scenario does not provide all the required elements for decision-making. One such element which was missing from this survey could have been the parents. It was shown in a previous study that for asymptomatic carious primary teeth, one-third of parents wanted the tooth to remain untreated but periodically monitored [Tickle et al., 2003].

The results indicate that there is no consensus among dentists who participated in this study regarding the optimal recommendations for the restoration of deep proximal carious lesions of primary molars. Traditional sources of evidence to support treatment recommendations include textbooks, conference proceedings, and clinical guidelines, which may not be based on well-conducted research [Forrest and Miller, 2003]. More well-designed clinical research studies assessing treatment outcomes in paediatric dentistry are needed for dentists to be able to support, and defend, their treatment decisions.

Conclusion

No clear consensus was evident among dentists practicing in Kuwait concerning the optimal treatment recommendations for the treatment of deep proximal carious lesions in primary molars. Differences in opinion appear to be due mainly to inter-individual, educational and training, and practice characteristic variations.

References

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American Academy of Pediatric Dentistry. Guidelines on pulp therapy for primary and young permanent teeth. Pediatr Dent 2005-2006;27:130-134.

Aryanpur S, van Niewenhuysen J-P, D'Hoore W. Endodontic retreatment decisions. Int Endod J 2000;33:208-218.

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Bader JD, Shugars DA. What do we know about how dentists make caries-related treatment decisions? Community Dent Oral Epidemiol 1997;25:97-103.

Carrotte P. Endodontic treatment for children. Br Dent J 2005;198:9-15.

Duggal MS, Nooh A, High A. Response of the primary pulp to inflammation: a review of the Leeds studies and challenges for the future. Eur J Paediatr Dent 2002;3:111-114.

Duggal MS, Day PF. Operative treatment of dental caries in the primary dentition. In: Welbury RR, Duggal MS, Hosey MT (eds). Paediatric Dentistry. 3rd ed. Oxrofd: Oxford University Press; 2005. pp 149-174.

Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000;22:278-286.

Field M, Lohr K. Clinical Practice Guidelines: Directions for a New Program. Washington: National Academy Press; 1990.

Forrest JL, Miller SA. Evidence-based decision making in action: Part 1-Finding the best clinical evidence. J Contemp Dent Pract 2002;3:10-26.

Forrest JL, Miller SA. Evidence-based decision making in action: Part 2. Evaluating and applying the clinical evidence. J Contemp Dent Pract 2003;4:42-52.

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Helminen SE, Vehkalati M, Murtomaa H. Dentists' perception of their treatment practices versus documented evidence. Int Den J 2002;52:71-74.

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Mejare I, Sundberg H, Espelid I, Tveit B. Caries assessment and restorative treatment thresholds reported by Swedish dentists. Acta Odontol Scand 1999;57:149-154.

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Tickle M, Milsom KM, Humphris GM, Blinkhorn AS. Parental attitudes to the care of the carious primary dentition. Br Dent J 2003;195:451-455.

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M. A. Qudeimat *, F. A. Al-Saiegh **, Q. Al-Omari **, R. Omar **

* Dept Developmental and Preventive Sciences; ** Dept Restorative Sciences, Kuwait University, Kuwait.

Postal address: Dr. M. A. Qudeimat. Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923 Safat- 13110 Kuwait.

Email: mqudeimat@hsc.edu.kw
Table 1 Frequencies of recommendations for the restoration of
the deeply carious primary second molar in a study concerning
dentists practicing in Kuwait.

Recommendation Number (%)

Do nothing 1 (0.6)
Monitor until exfoliation 1 (0.6)
Remove caries and restore 61 (39.4)
Pulpotomy and definitive restoration 82 (52.9)
Pulpectomy and definitive restoration 9 (5.8)
Extraction with or without space management 1 (0.6)

Total 155 (100)

Table 2 Characteristics of dentists practicing in Kuwait, choosing to
restore the tooth without and with prior pulp therapy.

 Recommended Optimal
 Treatment

 Restoration without
Variable pulp therapy (%)

Gender 52 (45)
 Males 9 (24)
 Females

Age
 [less than or equal to]35 years 20 (31)
 36-49 years 21 (40)
 [greater than or equal to]50 years 20 (56)

Country of Undergraduate Dental Education
 North America 4 (22)
 Western Europe 3 (23)
 Eastern Europe 8 (44)
 Middle East 29 (44)
 Asia 17 (46)

Undergraduate Dental Education Language
 English 47 (42)
 Non-English 14 (35)

Speciality
 General Dental Practitioner 23 (32)
 Paediatric Dentistry 2 (13)
 All Other Specialties 36 (55)

Country of Specialty Dental Education
 North American 5 (25)
 Western Europe 3 (50)
 Eastern Europe 3 (50)
 Middle East 12 (55)
 Asia 15 (56)
 General Dental Practitioner 23 (32)

Work Place
 Government 46 (42)
 Private 15 (36)

Area of Practice
 Suburban 13 (39)
 Urban 48 (40)

Number of Children Treated during a Week
 None but had in the past 18 (47)
 < 6 children 26 (52)
 6-16 child 11 (35)
 > 16 child 6 (18)

 Recommended Optimal
 Treatment

 Restoration with
Variable pulp therapy (%)

Gender 63 (55)
 Males 28 (76)
 Females

Age
 [less than or equal to]35 years 44 (69)
 36-49 years 31 (60)
 [greater than or equal to]50 years 16 (44)

Country of Undergraduate Dental Education
 North America 14 (78)
 Western Europe 10 (77)
 Eastern Europe 10 (56)
 Middle East 37 (56)
 Asia 20 (54)

Undergraduate Dental Education Language
 English 65 (58)
 Non-English 26 (65)

Speciality
 General Dental Practitioner 48 (68)
 Paediatric Dentistry 13 (87)
 All Other Specialties 30 (45)

Country of Specialty Dental Education
 North American 15 (75)
 Western Europe 3 (50)
 Eastern Europe 3 (50)
 Middle East 10 (45)
 Asia 12 (44)
 General Dental Practitioner 48 (68)

Work Place
 Government 64 (58)
 Private 27 (64)

Area of Practice
 Suburban 20 (61)
 Urban 71 (60)

Number of Children Treated during a Week
 None but had in the past 20 (53)
 < 6 children 24 (48)
 6-16 child 20 (65)
 > 16 child 27 (82)

 Recommended Optimal
 Treatment

Variable Total

Gender
 Males 115
 Females 37

Age
 [less than or equal to]35 years 64
 36-49 years 52
 [greater than or equal to]50 years 36

Country of Undergraduate Dental Education
 North America 18
 Western Europe 13
 Eastern Europe 18
 Middle East 66
 Asia 37

Undergraduate Dental Education Language
 English 112
 Non-English 40

Speciality
 General Dental Practitioner 71
 Paediatric Dentistry 15
 All Other Specialties 66

Country of Specialty Dental Education
 North American 20
 Western Europe 6
 Eastern Europe 6
 Middle East 22
 Asia 27
 General Dental Practitioner 71

Work Place
 Government 110
 Private 42

Area of Practice
 Suburban 33
 Urban 119

Number of Children Treated during a Week
 None but had in the past 38
 < 6 children 50
 6-16 child 31
 > 16 child 33

Table 3 Logistic regression model for in a study concerning dentists
practicing in Kuwait, who chose to restore the tooth without pulp
therapy versus those who recommended pulp therapy prior to definitive
restoration.

 Odd Confidence
Variable Ratios Interval P

Gender
 Males 0.26 0.08- 0.85 0.03
 Females (reference) -- -- --

Age
 [less than or equal to]35 years 3.32 0.93- 11.95 0.07
 36-49 years 1.98 0.56- 7.07 0.29
 [greater than or equal to]50 -- -- --
 years (reference)

Country of Undergraduate Dental
 Education
 Asia (reference) -- -- --
 North America 0.26 0.02- 3.40 0.3
 Western Europe 0.32 0.03- 4.03 0.38
 Eastern Europe 0.16 0.00- 0.25 0.004
 Middle East 0.01 0.01- 0.55 0.01

Language of Dental Education
 English 0.16 0.3- 0.72 0.02
 Non-English (reference) -- -- --

Specialty
 General Dental Practitioner -- -- --
 (reference)
 Paediatric Dentistry 7.37 0.91- 59.52 0.06
 All Other Specialties 1.41 0.16- 12.47 0.76

Country of Specialty Dental
 Education
 Asia (reference) -- -- --
 General Dental Practitioner -- -- --
 (reference)
 North American 12.61 0.82- 194.44 0.07
 Western Europe 1.54 0.10- 23.48 0.76
 Eastern Europe 9.82 0.40- 242.54 0.16
 Middle East 11.8 0.91- 153.06 0.06

Work Place
 Government (reference) -- -- --
 Private 1.91 0.40- 3.51 0.75

Area of Practice
 Suburban (reference) -- -- --
 Urban 0.88 0.28- 2.81 0.83

Number of Children Treated
 during a Week
 None but had in the -- -- --
 past (reference)
 < 6 children 0.14 0.03- 0.79 0.02
 6-16 children 0.12 0.03- 0.55 0.01
 > 16 children 0.27 0.07- 1.11 0.07

--2LL improvement: 163.7, df = 19, P<0.002
74.3% predicted correctly
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Article Details
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Author:Qudeimat, M.A.; Al-Saiegh, F.A.; Al-Omari, Q.; Omar, R.
Publication:European Archives of Paediatric Dentistry
Article Type:Clinical report
Geographic Code:7KUWA
Date:Mar 1, 2007
Words:4285
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