|Ahead of print publication
Caries-related treatment decisions of general dental practitioners in Riyadh, Saudi Arabia
Marwa Eltayeb Elagra1, Haya Fahad Alzaid2, Mai Mohammad Alsabeh2, Nada Abdulaziz Altoub2, Sahar Fahad Binhowaimel2
1 Department of Prosthodontics, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
2 Department of Dental Intern, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
Haya Fahad Alzaid,
College of Dentistry, Riyadh Elm University, Riyadh 12734
Source of Support: None, Conflict of Interest: None
Introduction: For decades, caries management strategies followed G. V. Black's concept, which has been considered an invasive approach since the development of operative care. Several studies showed a wide variation in restorative treatment decisions even among dentists within the same country.
Aim: The aim of this study is to investigate treatment decisions for carious lesions in relation to the patients' caries risk among general practitioners.
Materials and Methods: A cross-sectional study using a self-administered paper-based questionnaire was conducted among general dental practitioners in Riyadh city. The demographic characteristics of the practitioners were obtained. The questionnaire included five clinical scenarios aided by photographs; each scenario involved either a high- or a low-caries risk condition, and the scenarios were presented alternately. The recall interval was recorded. Occlusal and proximal caries thresholds were also explored. Data were analyzed using SPSS version 21 software. Chi-square and logistic regression analyses were conducted, and values of P ≤ 0.05 were considered statistically significant.
Results: A total of 340 participants were included in the analysis. The treatment decisions of the general dental practitioners for the International Caries Detection and Assessment System code 2 scenarios were mostly preventive. Proximal carious lesions extending to the dentinoenamel junction were the principal indication for operative treatment. Most participants preferred to recall patients after 6 months.
Conclusion: There was vast discordance between knowledge and practice in restorative treatment decisions for occlusal carious lesions. The general dentists tended to opt for restorative treatment in high-risk patients three times more often than in low-risk patients.
Clinical Significance: A low level of clinical implementation of evidence-based information was observed in this study regarding occlusal caries.
Keywords: Caries risk, carious lesions, minimally invasive dentistry, recall intervals, treatment decision
|How to cite this URL:|
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 [Epub ahead of print] [cited 2020 Aug 10]. Available from: http://www.saudijos.org/preprintarticle.asp?id=279062
| Introduction|| |
For decades, caries management strategies followed G. V. Black's (extension for prevention) concept, which incorporated the idea of removing susceptible areas of carious invasion alongside areas that are infected with caries. Nowadays, this approach considered an invasive approach since the development of adhesive dentistry and minimally invasive dentistry (MID) that adopted the concept of preventing and arresting the development of caries. With the understanding of the demineralization and remineralization, processes of lesions affected by caries.,,, This modern concept focuses on preventing causes rather than treating symptoms and includes the remineralization of early carious lesions, preventing demineralization and cavitation by reducing cariogenic bacteria, repairing defective restorations rather than replacing them, controlling disease, and treating cavitated lesions with minimal surgical intervention.,
Variations in caries progression levels means a general practitioner must decide whether a preventive or a restorative approach will be beneficial., However, decisions differ between dentists, even when confronted with the same clinical scenario. Several studies have shown wide variation in restorative treatment decisions among different countries and among dentists within the same country.,, For instance, the majority of general dental practitioners in Kuwait would postpone restorative treatment for a proximal carious lesion until it reached the outer third of the dentin and restore occlusal carious lesions reaching the middle third of dentin. In contrast, dentists in California tend to restore carious lesions at an earlier stage. Factors such as learned concepts, years of experience, and governmental versus private settings, along with other variables, are responsible for the differences in the treatment approaches between dentists.
In Saudi Arabia, dental caries is considered a prevalent disease. A study in Saudi Arabia found that the majority of general dentists (59.01%) lacked education and/or training regarding MID. This could lead to a high incidence of removing unnecessary tooth structures, irritating pulp tissues, and weakening tooth structures. Few studies in Saudi Arabia have discussed practitioners' restorative preferences and thresholds. To the best of our knowledge, no previous study has explored the management of carious lesions with regard to the patients' caries risk.
Thus, the aim of this study is to investigate the treatment decisions for carious lesions among general practitioners in relation to the patients' caries risk in Riyadh, Saudi Arabia and also, to explore the statistical associations between the general practitioners' demographic characteristics and the type of treatment approach.
| Materials and Methods|| |
This cross-sectional, observational study employing a self-administered paper-based questionnaire was approved by the Institutional Review Board of the university's research center (RC/IRB/2018/1135). The questionnaire was reproduced from Gomez et al. with the authors' permission. According to the Statistical Yearbook of the Ministry of Health, (2016) and Alsalleeh et al., there were 2304 general dentists in Riyadh City., Therefore, a sample size of 334 was determined after considering the 95% confidence level and 5% confidence interval (CI).
Following a pilot study involving 15 general dentists, in September of 2018, a questionnaire was distributed among general dental practitioners using a convenience sample based on the first available dentists in all five regions of Riyadh city, Saudi Arabia (north, west, central, east, and south regions). General dentists in governmental and private hospitals were approached. However, university hospitals and students were excluded from this study, due to the high influence of academic standards on their practice [Table 1]. The questionnaire was divided into three sections. The first section included five clinical scenarios aided by photographs [Figure 1]. These scenarios were presented in two forms: a high caries risk condition or a low caries risk condition. They were distributed randomly. Each participant answered questions regarding the five clinical scenarios involving either a high caries risk condition or a low risk condition alternately. Afterward, the recall interval was decided by the participant for each clinical scenario. The second section contained different stages of occlusal caries thresholds and proximal caries thresholds reproduced from Gomez et al. and Epsteine et al. (1997), respectively., Radiographs and pictures were scored following the International Caries Detection and Assessment System (ICDAS), which was developed based on the principles of evidence-based dentistry to measure and standardize the grading of the extent of caries development. The participants were then asked to choose either preventive or surgical treatment options. The descriptions of the caries extent for each scenario, occlusal thresholds, and proximal thresholds are presented in [Table 2]. The third section asked the participants to report their demographic characteristics, including gender, nationality, year of graduation, university, and type of practice. Informed consent was obtained from the participants after they received a brief introduction about the research purpose. The participant's personal information was anonymized to preserve privacy and confidentiality. No incentives were provided for their participation in the study.
|Figure 1: Clinical Scenarios (reproduced with permission from Gomez et al., 2014)|
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|Table 2: Descriptions of caries extent of each scenario, occlusal thresholds, and proximal thresholds|
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The data were analyzed using the IBM SPSS Statistics for Windows, Version 23.0. (IBM Corp., Armonk, NY). Statistical analyses included frequency distributions and Chi-square tests, which were conducted to detect any significant differences between demographic characteristics and caries risk in relation to the clinical scenarios and restorative thresholds. A value of P ≤ 0.05 was considered statistically significant. The odds ratio (OR) was calculated using logistic regression analysis.
| Results|| |
From a total of 368 dentists initially screened to participate in this study, 28 did not meet the study inclusion criteria [Table 1]. Therefore, 340 participants were finally included (52.4%) of the participants were males and (47.6) were females. The majority of the respondents practiced in the private sector (71.5%), and the remaining 28.5% practiced in the governmental sector [Table 3].
The treatment decisions of the general dental practitioners in scenarios 1 and 2 tended to be preventive (66.18% and 66.76%, respectively). The results for scenario 1 to 5 by risk are described in [Table 4]. Regarding the occlusal caries thresholds, 84.7% of the participants intend to restore C3 [Figure 2]. In addition, 87.35% of the general dental practitioners treated scenario 3 operatively. Similarly, for the proximal caries thresholds, the majority of practitioners choose to restore proximal carious lesions at the dentinoenamel junction (DEJ) R2 [Figure 2].
|Figure 2: (a) Preventive and restorative treatment decisions of clinical and radiograph thresholds (n = 340). (b) Occlusal pictures and radiographs reproduced with permission from Gomez et al., 2014 and Epsteine et al., 1997 (Norwegian Dent J), respectively|
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The patient's caries risk was considered by the general dentists in deciding the recall interval and showed statistically significant results in all the clinical scenarios, except for scenario 5 [Table 5]. The majority of the participants preferred a 6-month recall interval followed by a 3-month recall interval [Figure 3]. Moreover, the type of intervention in most of the clinical scenarios was influenced by the caries risk. For instance, in ICDAS Code 3 (scenario 4) where low-risk patients had a relatively high percentage of preventive treatment. While in scenario 2, the patients with high caries risk had a restorative intervention rate three times higher than the patients with low caries risk (OR: 2.62, CI: 1.63–4.21, P <0.001)[Table 5].
|Table 5: Association between participants' demographic characteristics and treatment decisions (preventive/operative) for scenarios 1-5 (n=340)|
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|Figure 3: Recall intervals in relation to scenarios and caries risk (n = 340)|
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| Discussion|| |
This study explored caries-related treatment decisions among general dentists in Riyadh city. The study was divided geographically into five regions, the north, east, west, south, and center regions, to ensure that the study covered all parts of the city.
Both governmental- and private practice-based general dentists were approached. The number of participants from the governmental sector was less than that from the private sector since the number of governmental dental clinics and general dental practitioners is less than that of private clinics. However, samples from governmental clinics were collected from all areas of Riyadh city. The demographic characteristics showed a nearly equal number of males and females, allowing the opportunity to explore any significant differences in their perceptions toward treatments.
Graduation year had an influence on the treatment decision. All the recent graduates who graduated after 2015 decided on preventive treatment when treating initial proximal caries. A systematic review in 2017 found that young dentists were more conservative than old dentists when proximal carious lesions were confined to the enamel. Moreover, the review showed that the type of practice had no impact on the treatment approach, supporting the results of the current study, which found no significant differences between the private and governmental clinics regarding the decision for operative treatment.
Gender did not have any impact on the treatment approach in the clinical scenarios, which supports earlier findings by Geibel et al. In contrast, Riley et al. found that female dentists took more preventive measures than male dentists.
In this study, the general dentists seemed to have vast discordance between knowledge and practice, although scenarios 1 and 2 and photograph C3 are all considered to be under ICDAS code 2. When the practitioners were faced with occlusal scenarios 1 and 2, in which the caries were confined to the inner half of the enamel, they tended to prefer a preventive treatment approach (66.18% and 66.76%, respectively). These findings support the results of Gomez et al., 2014. When confronted with clinical occlusal photograph C3 [Figure 2], which required their evaluation and judgment of the extent of decay, 84.7% of the dentists took an operative approach. This may indicate a low level of clinical implementation of evidence-based information. The dentists seemed to still advocate restoring early carious lesions. Training in dental schools should focus more attention to the clinical management of carious lesions.
Radiographic proximal caries thresholds (R2) and clinical proximal carious lesions (scenario 3) were treated invasively. The majority of the general dentists (60.6%) indicated that they intervene operatively when the proximal carious lesions reach the DEJ [Figure 2]. This finding is consistent with the global literature stating that operative treatment is initiated when carious lesions extend to the DEJ.,,, This is in contrast to the strategy of managing proximal caries by Kuwaiti and German dentists who prefer to delay operative treatment of proximal caries until decay reaches the outer third of the dentin.,
Early intervention and the immediate restoration of carious lesions may cause irritation and trauma to the pulp, weaken the tooth structure, and jeopardize the long-term prognosis., Preventive measures, such as resin infiltration, have proven to be successful for noncavitated carious lesions up to the outer third of the dentin., Furthermore, MID has the advantages of saving time, effort, costs, and preserving tooth structure., A review by Kaidonis et al. from Adelaide University incorporated MID into the dental curriculum and showed fairly successful results. Dental curricula should emphasize MID and implement such new concepts. For instance, providing the students with a realistic plastic model that simulates the dental tissues (pulp, dentine, and enamel) with different stages of caries progression could develop and improve their manual skills.
In the current study, the determination of the type of intervention in relation to the patients' caries risk was statistically significant [Table 5]. High-caries risk patients were treated operatively more often than low-caries risk patients. For instance, in scenario 2, the operative treatment rate in patients with high caries risk was three times higher than that in patients with low caries risk (OR: 2.62, CI: 1.63–4.21, P < 0.001). According to the International Caries Classification and Management System Guide for Practitioners and Educators, when treating carious lesions, operative intervention should be the last resort after home care and clinical preventive measures. Similarly, when treating high-risk patients, preventive measures should be considered and performed frequently. Managing carious lesions according to a patient's risk should be investigated thoroughly by researchers.
The choice of dental restorative material is currently of interest; amalgam was the restorative material of choice before the development of composite. Since the 1990s, the shift from amalgam to composite restorations has gained great attention in dental practices. A recent study showed that 80.7% of dentists and interns in Riyadh did not frequently use amalgam in their practices. The practitioners reported esthetics and patients' desires as the reason for choosing composite over amalgam. These findings support the results of the current study, in which there was a predominant tendency toward composite over amalgam in all the scenarios.
In this study, the patient's caries risk was greatly considered when deciding the treatment and recall interval. However, other patient factors, such as age, recall interval, recall need integration, and patient attendance, were overlooked by the participants. Recall intervals are considered a secondary prevention strategy, as they prevents tooth loss through early prevention and the promotion of oral health. In the current study, the majority of general dental practitioners preferred a 6-month recall interval, followed by a 3-month interval [Figure 3]. However, the 6-month “one-interval-fits-all” recall interval has been a traditional recall interval since the 1970s and is still a matter of debate.,, In a previous study, Patel et al. mentioned that recalling patients with low caries risk every 6 months could be too frequent and may put the patient at risk of overtreatment. In addition, Sheiham stated that recall visits of 18 months are appropriate for adult patients. However, the National Institute for Health and Care Excellence guideline recommends that recall intervals should be tailored for each patient based on his or her disease level and risk. This can be applied by considering five elements: Patient age, risk factors, recall need integration, examination results, and reevaluation of the initial recall interval. Clinical trials should be conducted to evaluate the process of recall interval determination considering all the clinical factors present in daily practice.
The authors recommend that further studies, including clinical trials, should be initiated in other regions of Saudi Arabia and worldwide to develop a standardized global treatment approach for different stages of caries and to integrate theoretical knowledge into the daily practice of practitioners by enhancing dental curricula, practical dental school training, and continuous education.
| Conclusion|| |
The current study showed vast discordance between knowledge and practice in the restorative treatment decisions of occlusal carious lesions. However, proximal carious lesions extending to the DEJ were the first indication for operative treatment. General dentists in this study showed preference for restorative rather than preventive approaches, especially in high-risk patients. Gender and type of practice had no influence on the treatment decisions.
Random sampling has less risk of carrying errors. However, the authors faced difficulties in achieving this type of sampling, due to the refusal of some hospitals to participate in this study. Therefore, convenience sampling was used. Participants may have had some difficulties in diagnosing and choosing the type of treatment through photographs only.
The authors would like to thank Dalya Alanazi, Saleh AlHammad, and Saleh AlHatlani for their valuable help in collecting the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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