It has been observed that primary teeth are lost prematurely despite the advancements in the way we see and treat dental caries . A clinician would be in dilemma at times with respect to the diagnosis and treatment options for deep carious lesion which is in close proximity to the pulp of primary teeth. The anatomical, physiological and pathological differences in dentin-pulp complexes between primary and permanent teeth further complicate the treatment choice .
The newly advocated procedure of IPT of step-wise caries excavation is gaining popularity among certain clinicians as it is more conservative when compared to traditional Indirect Pulp Capping (IPC) and this being a step-wise caries excavation procedure, either delays or avoids pulp exposure . In this procedure, carious dentin is partially removed and a biocompatible material is placed on it and the cavity is sealed. This arrests the caries process and causes dentin sclerosis, induces tertiary dentin formation, and thereby remineralizing the remaining carious dentin .
Clinicians may perform the vital pulp therapy of their choice in case of a deep carious lesion with a probable pulp exposure. Their decision depends on their knowledge and training undertaken related to the procedure  and their level of experience and skill to perform it in a child . As there is no consensus on the treatment planning of a deep carious lesion in primary teeth among dentists, the present survey was aimed to assess and compare the perspective of general and paediatric dentists’ of Saudi Arabia with regard to vital pulp therapy in primary teeth.
Materials and Methods
A cross-sectional survey was planned for a period of three months using close-ended, multiple-choice questionnaire directed to evaluate the perspective of general and paediatric dentists of Saudi Arabia towards pulp therapy in primary teeth. The questionnaire was adopted from the study done by Nayak UA et al., which consisted of a total of 19 questions . The questionnaire was re-validated and its construct, face, and content validities were carried out with the help of 5 randomly-selected dentists with vast clinical and teaching experience. The difficulty in understanding each question, its interpretation, and its correctness was critically analysed. The modifications were accordingly, carried out and the proforma was finalised. The ethical clearance was obtained from the institutional ethical committee of Ibn Sina National College for Medical Studies, Jeddah (IHEC Ref no: H-23-30042018). Anticipating the knowledge among the Paediatric dentists to be at least 50% more than the general dentists with a 95% confidence level at 80% power and a ratio of 1:2 for Paediatric dentists to general dentist, accounting for a 20% non-response rate, a minimum of 40 paediatric dentists and 80 general dentist needed to be included in the present study.
The questionnaire containing multiple choice questions was then mailed to general dentists and paediatric dentists across Kingdom of Saudi Arabia. They were asked to make the best choice from the options available. The participating dentists’ consent was obtained after assuring that their identity would be kept strictly confidential. The study was planned from 1st September 2018 to 30th November 2018, till the desired sample size of 100 general dentists and 50 paediatric dentists was obtained.
The responses were received, entered on Microsoft Excel (Microsoft, Redmond, WA, USA) and analysed using IBM SPSS version 20. Descriptive statistics followed by χ2-test was applied to test of variables in the questionnaire to determine their association.
The work profile of the general and paediatric dentists is shown in [Table/Fig-1]. It describes their distribution based on their experience and frequency of treating child patients in their dental clinic. Fifty paediatric dentists and 100 general dentists were enrolled for the study.
Work profile and experience of general dentist and paediatric dentists.
|Work profile of dentists|
|General dentists||100 (66.7%)|
|Paediatric dentists||50 (33.3%)|
|Experience of dentists|
|General dentists N (%)||Paediatric dentists N (%)|
|0-5 years||63 (63%)||07 (14%)|
|5-10 years||31 (31%)||18 (36%)|
|10-20 years||04 (4%)||19 (38%)|
|>20 years||02 (2%)||06 (12%)|
|Frequency of treating child patient in general practice|
|General dentists N (%)||Paediatric dentists N (%)|
|1-12 per week||88 (88%)||12 (24%)|
|13-24 per week||09 (9%)||24 (48%)|
|>25 per week||03 (3%)||14 (28%)|
[Table/Fig-2] suggests that 62% of general dentists and 78% of paediatric dentists did not plan treatment of deep carious teeth just based on radiographs. The comparison was statistically non-significant (p=0.064). Regarding the choice of procedure performed in case of deep carious lesion with probability of pulpal exposure, most of them preferred pulpotomy followed by IPC. The least preferred procedure by paediatric dentists was direct pulp capping (4%) and by general dentists was pulpectomy (7%). However, the comparison was statistically non-significant (p=0.493).
Dentists approach towards probable carious exposure of pulp in case of deep caries lesion.
|Variables||General dentists n (%)||Paediatric dentists n (%)||Chi square value||p-value|
|Planning treatment just based on radiograph prior to caries excavation||Yes||38 (38%)||11 (22%)||3.880||0.064|
|No||62 (62%)||39 (78%)|
|Procedure often performed in case of deep carious lesion in a primary molar with probability of pulpal exposure||Indirect pulp capping||17 (17%)||8 (16%)||2.405||0.493|
|Direct pulp capping||11 (11%)||2 (4%)|
|Pulpotomy||65 (65%)||35 (70%)|
|Pulpectomy||7 (7%)||5 (10%)|
*Significant at p<.05
The Paediatric dentists (68%) used rubber dam isolation more frequently when compared to the general dentists (47%) during pulp therapy in primary teeth and this comparison was statistically significant (p=0.025) [Table/Fig-3]. However, 32% of Paediatric dentists and 53% of general dentist did not practice rubber dam isolation during pulp therapy in children.
Frequency of rubber dam use during vital pulp therapy in primary teeth.
|Variables||General dentists n (%)||Paediatric dentists n (%)||χ2-value||p-value|
|Frequency of rubber dam use during vital pulp therapy in primary teeth||Not at all||53 (53%)||16 (32%)||9.388||0.025|
|Less than 50% cases||26 (26%)||24 (48%)|
|More than 50% cases||6 (6%)||5 (10%)|
|All cases||15 (15%)||5 (10%)|
*Significant at p<.05
[Table/Fig-4] shows that while performing indirect pulp capping in primary teeth, both the general dentists (65%) and paediatric dentists (56%) preferred using local anaesthesia for pain control in all cases but the comparison was not statistically significant. Paediatric dentists (62%) preferred using caries detector dye to facilitate caries removal as a part of IPC significantly more frequently than general dentists (34%) (p=0.001).
Practices followed during Indirect pulp capping procedure.
|Variables||General dentists no. (%)||Paediatric dentists no. (%)||Chi square value||p-value|
|Frequency of local anaesthesia used||Always||65 (65%)||28 (56%)||2.347||0.309|
|Sometimes||29 (29%)||21 (42%)|
|Rarely||6 (6%)||1 (2%)|
|Frequency of caries detector dye used||Always||11 (11%)||3 (6%)||16.566||0.001|
|Sometimes||15 (15%)||16 (32%)|
|Rarely||8 (8%)||12 (24%)|
|Never||66 (66%)||19 (38%)|
|Order of preference for determinants of IPT1. Dentin quality2. Lesion depth3. Clinical signs and symptoms, along with radiographic appearance||1,2,3||17 (17%)||5 (10%)||6.105||0.107|
|2,3,1||17 (17%)||17 (34%)|
|3,1,2||27 (27%)||10 (20%)|
|3,2,1||39 (39%)||18 (36%)|
|Method followed and number of visit||1 visit procedure||43 (43%)||32 (64%)||5.880||0.053|
|2 visit procedure without re-entry||35 (35%)||11 (22%)|
|2 visit procedure with re-entry||22 (22%)||7 (14%)|
*Significant at p<.05
Both general dentists (39%) and paediatric dentists (36%) gave more emphasis on clinical signs and symptoms along with radiographic appearance, followed by lesion depth and dentin quality as their order of preference regarding determinants of IPT. The comparison was statistically non-significant (p=0.107).
Most of the general dentists (43%) and paediatric dentists (64%) practised indirect pulp therapy as a one-visit procedure. Only 22% of general dentists and 14% of paediatric dentists recalled their patients for second visit and re-entered the area to evaluate the remaining carious dentin. However, there were no significant differences between them with regard to the method followed and the number of visits deployed for the procedure (p=0.053).
When the complete caries excavation would lead to pulp exposure, both the general dentists (70%) and paediatric dentists (76%) preferred pulpotomy as the procedure of choice. 30% of general dentists and 24% of paediatric dentists were more conservative in their approach and preferred indirect pulp capping [Table/Fig-5]. However, their approach was similar with no statistically significant difference (p=0.440).
Preferences of vital pulpal procedures in cases of deep caries with probable pulpal exposure.
|Variables||General dentists no. (%)||Paediatric dentists no. (%)||Chi-square value||p-value|
|Preference of IPC over pulpotomy||Yes||30 (30%)||12 (24%)||0.595||0.440|
|No||70 (70%)||38 (76%)|
|Preference of treatment in case of mechanical pulp exposure||Direct pulp capping||34 (34%)||10 (20%)||5.712||0.126|
|Pulpotomy||59 (59%)||39 (78%)|
|Single visit pulpectomy||6 (6%)||1 (2%)|
|Multiple visit pulpectomy||1 (1%)||0 (0%)|
|When indicated, preference of one-visit pulpectomy over pulpotomy||Always||29 (29%)||19 (38%)||1.534||0.674|
|More than 50% of the cases||23 (23%)||10 (20%)|
|Less than 50% of the cases||17 (17%)||6 (12%)|
|Never||31 (31%)||15 (30%)|
*Significant at p<.05. IPC: Indirect pulp capping
When there was a mechanical pulp exposure, pulpotomy was the preferred treatment option followed by direct pulp capping in both general dentists and paediatric dentists. Single visit pulpectomy was practised only by 6% of general dentists and 2% of paediatric dentists. Multiple visit pulpectomy was seldom practised (1% of general dentists). The comparison of their preferences was non-significant (p=0.126). A 31% of general dentists and 30% of paediatric dentists preferred performing pulpotomy rather than single visit pulpectomy when indicated and the comparison was not statistically significant (p=0.674).
[Table/Fig-6] suggests that Zinc Oxide Eugenol (ZnOE) was the preferred material for obturation of primary teeth as reported by general dentists (55%) and paediatric dentists (46%). Second option preferred was the combination of calcium hydroxide and iodoform, by 23% general dentists and 42% paediatric dentists. There was no statistically significant difference in the choice of obturating material between the groups. The general dentists (73%) and paediatric dentists (78%) believed that state of tooth or its diagnosis did not determine the choice of obturating material (p=0.556).
Preferences of dentists regarding Pulpectomy in primary teeth.
|Variables||General dentists no. (%)||Paediatric dentists no. (%)||Chi-square value||p-value|
|Material of choice for root canal filling||ZOE||55 (55%)||23 (46%)||9.448||0.051|
|Calcium hydroxide||21 (21%)||5 (10%)|
|Calcium hydroxide+iodoform||23 (23%)||21 (42%)|
|Other||1 (1%)||1 (2%)|
|Whether choice of material for obturation depends on tooth diagnosis||Yes||27 (27%)||11 (22%)||0.441||0.556|
|No||73 (73%)||39 (78%)|
|Restoration of choice after pulpotomy or pulpectomy||GIC||54 (54%)||12 (24%)||13.323||0.004|
|Reinforced GIC or Compomer||13 (13%)||11 (22%)|
|Composite resin||19 (19%)||12 (24%)|
|Full coverage restoration (SS crown)||14 (14%)||15 (30%)|
|The timing of placement of SS crown, if it is chosen to be placed after pulpotomy or pulpectomy||Same appointment||37 (37%)||30 (60%)||8.334||0.016|
|After 24 hours||22 (22%)||10 (20%)|
|After 7 days||41 (41%)||10 (20%)|
|Timing of radiographic evaluation||Only immediate post-operatively||57 (57%)||32 (64%)||0.947||0.623|
|Immediate post-operatively and after 3 months||40 (40%)||16 (32%)|
|Only if recalled next||3 (3%)||2 (4%)|
|Opinion that pulp therapy being less frequently performed||Yes||44 (44%)||40 (40%)||0.218||0.727|
|No||56 (56%)||60 (60%)|
*Significant at p<.05
Stainless Steel crown (SS Crown) (30%) was the choice of restoration after pulpotomy or pulpectomy by Paediatric dentists followed by GIC (24%)/composite (24%) and Reinforced GIC (22%). GIC (54%) was the preferred choice by general dentists followed by composite resin (19%), SS crown (14%) and Reinforced GIC (13%). This difference in their choice of post-endodontic restoration was statistically significant (p=0.004). A 60% of Paediatric dentists and 37% General dentists placed SS crown on the same appointment after pulpotomy or pulpectomy. A 41% of general dentists and 20% of paediatric dentists preferred to place SS crown after 7 days. This difference in timing of SS crown placement was statistically significant (p=0.016).
Most of general dentists (57%) and paediatric dentists (64%) practiced radiographic evaluation after pulp therapy at immediate post-operative period only. However, there was no statistical difference in their practice (p=0.623). Majority of the general dentists (56%) and paediatric dentists (60%) did not believe in the opinion that vital pulp therapy was less frequently performed in children but there was no statistical difference in their belief (p=0.727).
The primary objective of pulp therapy of primary teeth should be to maintain their integrity and health till they are shed and replaced . Although, the history taking is more subjective and less reliable in children, the management of deep carious lesion in a child would depend upon the clinical signs/symptoms, radiographic picture and level of co-operation exhibited by the child during the treatment. In the present study majority of clinicians did not plan treatment of deep carious teeth just based on radiographs and they relied on clinical picture.
Indirect pulp treatment is indicated for a deep carious lesion approximating the pulp without any signs or symptoms of pulp degeneration . Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies [9,10]. It is recommended that direct pulp capping should be used with caution in primary teeth due to the increased risk of internal resorption and calcifications . The Paediatric dentists in the present study thus, seldom performed direct pulp capping.
It has been reported that many paediatric dentists irrespective of their experience are neither using local anaesthesia nor caries detector dye while performing indirect pulp capping . It is now confirmed that caries detector dye stains both carious as well as sound dentin, resulting in over-zealous dentin removal and wider cavities . The excavation of infected carious dentin may be painless but vital tubular contents in affected dentin make its removal painful. The administration of local anaesthesia in such cases can significantly reduce this distinction . Only an experienced professional would be able to differentiate the dentin quality during caries removal . Therefore, the clinician can best decide this considering dentin quality, lesion depth, and clinical symptoms along with radiographic picture . In the present study, most clinicians stressed more importance to clinical signs/symptoms and their radiographic appearance, followed by lesion depth and dentin quality as their order of preference regarding determinants of IPT.
It is proven beyond doubt that when proper isolation is achieved during pulpotomy procedure, its success improves drastically and paediatric dentists of the present study believed in this concept. But in routine clinical practice, the use of rubber dam in younger or uncooperative children may be difficult or they may/may not prefer it . Some patients get a feeling of the procedure being performed outside of their mouth and hence tolerate treatment for longer time. However, it is recommended that dentists should calm the patient resistance and try to use a rubber dam wherever possible . The motivation and attitudes of the practicing dentist toward rubber dams directly influences the attitudes of child toward acceptance of rubber dam placement , as believed by the paediatric dentists of the current study.
In contrast to traditional indirect pulp capping, IPT is more conservative and involves second visit during which re-entry to the lesion as well as its assessment is done , which was practiced by fewer clinicians of present study. Similar findings were reported by Nayak UA et al., . Stepwise (two-step) caries excavation can result in fewer pulp exposures and lesser manifestations of pulpal disease when compared to complete caries excavation.
Although, indirect pulp therapy is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis and it does not delay its exfoliation time . When there is a mechanical pulp exposure, pulpotomy should be the preferred treatment option especially when the exposure size is larger than pin-point. The healing ability of the pulp of primary teeth is best predicted by proper diagnosis of its inflammatory status, which in turn dictates the success rate of pulpotomy .
Single-sitting pulpectomy is reported to be electively chosen over pulpotomy by certain paediatric dentists in case of a vital tooth as it has relatively higher success rates . However, in the present study, single-sitting pulpectomy was practiced by very few general as well as paediatric dentists which could be related to the lack of their exposure to the procedure during their training period and also preference of certain treatment options . Multiple visit pulpectomy was seldom practiced (1% of general dentists). The preference of single or multiple visit pulpectomy should be made according to its clinical feasibility and biological outcomes. Single-visit pulpectomy if performed following appropriate aseptic precautions and in controlled conditions may result in a very high success rate especially for teeth with apical periodontitis. The number of appointments may not have any relevance and the procedural steps can be accomplished in one sitting with desirable long-term success. Hence, single-visit pulpectomy can be recommended for treatment of primary teeth with apical periodontitis .
Zinc Oxide Eugenol (ZnOE) when used as an obturating material in primary teeth has anti-inflammatory/analgesic properties and is radio-opaque. However, its resorption rate is slower, and alters the path of tooth eruption of permanent successor . If it is in contact with periapical tissues, it can cause irritation and necrosis of cementum or bone. It is reported to have 93.3% success, which is lower than Metapex . But, overfilling and voids were more commonly seen in teeth filled with Metapex. Calcium hydroxide and iodoform combination has shown higher long term success and has excellent antibacterial effect; it is radiopaque and easy to use as it is available as premixed paste in a convenient syringe. However, when the pulpal inflammation is extensive to cause non-vital tooth, the use of combinations of minocycline, metronidazole and ciprofloxacin is preferred as it is more effective .
SSC should be routinely indicated post-pulpotomy or pulpectomy as it is durable, protects the brittle crown, improves the coronal seal and improves the success of vital pulp therapy. The most common reasons reported in literature for not preferring stainless steel crowns in children were related to their prolonged chair-side time, patient cooperation, the required skill of the dentist and the cost . A randomised control trial found no difference in survival rate for teeth restored with preformed metal crowns versus direct intra-coronal restorations such as light cured glass ionomer/composite restoration .
Most dentists practiced radiographic evaluation after pulp therapy at immediate post-operative period only. However, it is recommended that the long-term follow-up is practiced to ensure success of procedure of pulp and/or the restoration done and also to ensure that there are no undesirable effects on the surrounding oral tissues .
Limitation and Future Recommendation
The cross-sectional studies have the limitations that they are suggestive of the relevant facts for the said time period. However, further studies at regular intervals with comparisons regarding newer treatment modalities are warranted.
In the present study, most of the paediatric dentist prefered the placement of SSC after plupotomy or pulpectomy whereas general dentist prefered GIC restoration. The Correct time for placement of SSC was after seven days for most of the general dentist but paediatric dentist prefered placement of the crowns in the same appoinment.*Significant at p<.05*Significant at p<.05*Significant at p<.05*Significant at p<.05. IPC: Indirect pulp capping*Significant at p<.05