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Knowledge and practice of, and attitudes toward, pulp therapy in deciduous teeth among pediatric dentists in India

Aim: The aim of the present study was to assess the knowledge and practice of, and attitudes toward, pulp therapy in deciduous dentition among pediatric dentists. Methods: A cross-sectional, observational survey was conducted using a closed-ended,
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   J Invest Clin Dent.  2017;e12284. |   1 of 5© 2017 John Wiley & Sons Australia, Ltd Received: 29 August 2016 |  Accepted: 1 June 2017 DOI: 10.1111/jicd.12284 ORIGINAL ARTICLE Paedodontics Knowledge and practice of, and attitudes toward, pulp therapy in deciduous teeth among pediatric dentists in India Ullal A. Nayak 1   |  Saakshe Wadhwa 2   |  Nilotpol Kashyap 2   |  Deepesh Prajapati 2   |    Amit V. Mahuli 3   |  Reena Sharma 2 1 Department of Pediatric Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia 2 Department of Pedodontics and Preventive Dentistry, National Institute of Medical Science Dental College and Hospital, Jaipur, India 3 Department of Public Health Dentistry, National Institute of Medical Science Dental College and Hospital, Jaipur, India Correspondence Professor Ullal A. Nayak, Department of Pediatric Dentistry, Ibn Sina National College for Medical Studies, Jeddah, Saudi Arabia. Email:  Abstract  Aim : The aim of the present study was to assess the knowledge and practice of, and attitudes toward, pulp therapy in deciduous dentition among pediatric dentists. Methods : A cross- sectional, observational survey was conducted using a closed- ended, multiple- choice questionnaire evaluating the knowledge and practice of, and attitudes toward, pulp therapy in deciduous dentition, which was formulated and sent to 360 pediatric dentists across India. Descriptive statistics were done, followed by χ 2 - test to test the association between years of experience and the questionnaire items. Results : A total of 3.5% of pediatric dentists performed their treatment using a rubber dam in all cases; 30% preferred to use local anesthesia prior to indirect pulp therapy (IPT). Traditional indirect pulp capping was preferred to IPT, and only 48% of them believed in not removing it completely. Pulpotomy was preferred over IPT (70%) when there was a probability of pulp exposure following complete caries excavation. Calcium hydroxide, along with iodoform, was the material of choice for the obturation of pri-mary teeth (73.5%). A stainless steel crown was placed after pulp therapy in the pri-mary tooth (86.3%). Most dentists believed requested immediate and 3- month follow up. Conclusion : The survey helps in assessing whether our views or approaches are in line with recent trends. KEYWORDS indirect pulp capping, primary teeth, pulp therapy, pulpectomy, pulpotomy 1 |  INTRODUCTION The preservation of a primary tooth until its exfoliation is an important objective in maintaining proper dentition. Dental caries, an infectious and transmissible disease, is the most common chronic disease. 1 Pulp therapy in primary dentition is distinct from permanent den-tition due to the anatomic and morphological differences between them. 2  Many times, the clinician is at crossroads with respect to the diagnosis and treatment options to choose when there is a deep car-ies lesion with close proximity to the pulp. The rate of caries spread, dentin quality, lesion depth, clinical symptoms, clinician’s skill, and  judgements are factors that help in deciding a treatment option in these cases. 3 In contrast to traditional indirect pulp capping (IPC), where com-plete excavation of infected dentin is performed, leaving behind affected dentin, 4  the newly- advocated technique of indirect pulp therapy (IPT) has gained acceptance due to the advantage of pre-serving tooth vitality and causing minimal trauma to the pulp. 5  IPT is performed by incomplete removal of carious dentin and placement of a biocompatible material on the carious lesion, thereby reducing  2 of 5 |   NAYAK ET   AL . the bacterial count. 6  When such lesions are sealed, the substrate on which the bacteria act is also removed, leading to arrest of the carious process and promoting dentin sclerosis, tertiary dentin formation, and remineralization of carious dentin. The end result is that pulp vitality is maintained, and pulp exposure is either avoided or delayed. 7 Various clinical studies have shown that the success rate is high for both one- and two- visit IPT. 8-11  In one- visit IPT, the permanent restoration is carried out at the same visit, whereas in two- visit IPT, the intermediate restoration is performed before re- entry. After a spe-cific period of time, the cavity is reopened and final caries excavation is performed.When there is deep carious lesion with the probability of pulp ex-posure, certain clinicians are more radical in their approach, and have gained relatively good success by performing either pulpotomy or single- sitting pulpectomy. 12,13 As there is confusion regarding terminologies, and there is no consensus on the optimal treatment of a deep carious lesion among pediatric dentists, the present study was undertaken to aid pediatric dentists in successfully deciding whether to stop the carious removal, or when, without exposing the pulp. A thin line delineates the indica-tion, diagnosis, and treatment plan among various pulp therapies in primary teeth. Therefore, the aim of the present study was to assess the knowledge and practice of, and attitudes toward, pulp therapies in primary dentition among pediatric dentists in India. 2 |  MATERIALS AND METHODS A cross- sectional, questionnaire survey was conducted among pediatric dentists in India for a period of 2 months. Ethical clearance was obtained from the institutional ethical committee of National Institute of Medical Science University, Jaipur, India. A closed- ended, multiple- choice ques -tionnaire evaluating the knowledge and practice of, and attitudes toward, pulp therapy in primary dentition was constructed after prior validation. Construct, face, and content validities were carried out. The question-naire was sent to 10 randomly- selected, senior pediatric dentists with vast clinical and teaching experience. The questions were assessed for their difficulty in understanding, interpreting, and answering correctly. The modifications were done accordingly, and the pro forma was finalized. The questionnaire was randomly emailed to 360 pediatric dentists in India. They were asked to choose the most suitable answer from the available choices. The identity of the participating pediatric dentists was kept strictly confidential, and participation was voluntary. The responses were col-lected and computed on Microsoft Excel (Microsoft, Redmond, WA, USA) for analysis of the results using IBM SPSS version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics were done, followed by χ 2 - test to test the association between years of experience and the questionnaire items. 3 |  RESULTS A total of 306 pediatric dentists responded to the questionnaire, with an 85% response rate; 80% of pediatric dentists who participated in the study were academicians, as well as practitioners, and 94% of them had ≤20 years’ experience (Table 1). When there was a deep carious lesion with a probability of caries exposure on excavation, di-rect pulp capping was the least- preferred procedure, and most den-tists preferred pulpectomy, followed by pulpotomy and IPC. A total of 65% of pediatric dentists believed that assessing the treatment plan of deep carious lesions based on radiograph alone was not appropriate. They believed that clinical judgement was equally as important, if not more, in determining the treatment plan, and this was statistically sig-nificant (Table 2). The majority of pediatric dentists performed pulpal procedure without a rubber dam, and only 3.5% used a rubber dam in all cases ( P <.05, Table 3). A total of 30% of pediatric dentists preferred to use local anesthesia prior to IPT, with the rest using dentin sensitiv-ity as a guide for caries excavation. Only 6% of pediatric dentists used a caries detector dye to stain infected dentin prior to its excavation ( P =.029), and 52% performed complete removal of infected dentin in all cases ( P <.05). Therefore, they followed traditional IPC, rather than IPT, and only 48% believed in not removing it completely. Most pediatric dentists considered clinical signs and symptoms, along with radiographic appearances, important determinants for IPT. However, 12.7% also emphasized dentin quality and lesion depth (Table 4). A total of 70% of pediatric dentists preferred pulpotomy over IPT when there was a probability of pulp exposure following complete caries TABLE 1 Work profile and experience of pediatric dentists  VariableFrequency (n=306)% Work profile of pediatric dentistsClinician92.9Academician5718.6Both24078.4Experience of pediatric dentist0- 5 years10534.35- 10 years9029.410- 20 years9330.4>20 years185.9 TABLE 2 Deep carious lesion with probability of carious exposure of pulp on excavation Options Frequency (n=306)%  χ 2 - value  P - value Planning treatment just based on radiograph prior to caries excavationYes10534.334.498.000*No20165.7Choice of pulpal procedureIndirect pulp therapy9932.450.734.000*Direct pulp therapy123.9Pulpotomy8126.5Pulpectomy11437.3*Significant at P <.05.    |  3 of 5 NAYAK ET   AL . excavation. When pulpotomy was indicated, only 25% of pediatric dentists preferred to make an elective choice of performing single- sitting pulpectomy over pulpotomy. Most preferred pulpotomy over single- sitting pulpectomy (Table 5). Calcium hydroxide, along with iodoform, was the material of choice for the obturation of primary teeth (73.5%) (Table 6). A stainless steel crown was placed after pulp therapy in the primary tooth by 86.3% of pediatric dentists. Most of the pediatric dentists requested immediate and 3- month follow up (Table 6). 4 |  DISCUSSION The uniqueness of dental pulp, in that it defies visualization, makes it difficult to the clinician, and requires them to know a patient’s his-tory, clinical symptoms, and signs, as well as undertake vitality tests, in order to achieve a proper diagnosis and treatment plan. The indica-tions, objectives, and types of pulpal therapies depend on when the pulp is symptom free or there is reversible pulpitis, symptomatic or asymptomatic irreversible pulpitis, or a necrotic pulp. 14 The pediatric dentists in the present study followed a less conserva-tive approach, and were more radical toward the pulpal treatment (deep carious lesion with the probability of pulp exposure on excavation), as most preferred pulpectomy, followed by pulpotomy and IPT. Only a few preferred direct pulp capping. They also opted to perform pulpotomy over IPT when there was a probability of pulp exposure following deep caries removal.The literature suggests that single- sitting pulpectomy is electively chosen by certain pediatric dentists over pulpotomy in a vital tooth because the success of single- sitting pulpectomy is better than that of pulpotomy. 15  However, in the present study, they preferred pulpotomy over single- sitting pulpectomy. There has been lack of consensus re-garding the selection and application of certain treatment options and techniques taught for primary tooth pulp therapy in predoctoral dental programs in the USA. 16 It is an accepted fact that the success of a pulpal procedure drasti-cally increases when performed under a rubber dam, but in the present study, there was limited dental dam use. This is supported by another study, in which 97% of respondents reported that patients do not like rubber dam. In contrast to this, there is evidence that many patients pre-fer to have it placed. 17  However, Wolcott and Goodman reported that dentists might rationalize their failure to use a rubber dam by claiming Rubber dam use Frequency (n=306)%  χ 2 - value  P - value Not at all10835.337.112.000*<50%13544.1>50%5116.7All cases123.9*Significant at P <.05. TABLE 3 Rubber dam use in pulp therapy in primary teeth  VariableFrequency (n=306)%  χ 2 - value  P - value IPT over pulpotomyYes7825.53.719.715No21670.6Other reason123.9Single- sitting pulpectomy over pulpotomyNo12340.27.267.297Less than 50%10534.3More than 50%7825.5*Significant at P <.05. IPT, indirect pulp therapy. TABLE 5 Choice of pulpotomy over other procedures in cases of complete caries removal leading to pulpal exposure TABLE 4 Indirect pulp therapy (IPT) procedure  VariablesFrequency (n=306)% χ 2 - value  P - value Use of local anesthesiaYes9330.43.648.302No21369.6Carious detector dye useYes185.98.993.029*No28894.1Complete excavation of infected dentinYes15952.024.852.000*No14748.0Determinants for IPTDentin quality3912.718.845.004*Lesion depth3912.7Clinical signs and symptoms, along with radiographic appearance22874.5*Significant at P <.05.  4 of 5 |   NAYAK ET   AL . patient resistance. 18  Dentists’ motivation and positive attitudes toward rubber dams is a factor that influences patients’ attitudes toward rub-ber dam application, thereby increasing patient acceptance. 17 The use of local anesthesia and carious detector dye in IPT was not recommended by the majority of pediatric dentists in the present study. Caries- disclosing dyes were thought to stain only the outer in-fected dentin, 19,20  but recent studies suggests that these dyes stain sound and carious dentin, leading to the overpreparation of cavities, which can be clinically significant. 21,22  The removal of infected carious dentin is painless, whereas demineralized dentin is very painful due to vital tubular contents. This distinction can be lost, however, when the tooth is anesthetized. 23  A study concluded that an experienced professional can slightly differentiate the dentin quality during caries removal. 24  Therefore, the decision should preferably made by the clini-cian based on the quality of the dentin, the depth of the lesion, and the clinical symptoms, as well as radiographic appearance. 2,3 Evidence from randomized, controlled trials and systematic reviews confirm that incomplete caries excavation in primary and permanent teeth with normal pulps or reversible pulpitis, either partial (one- step) or stepwise (two- step) excavation, results in fewer pulp exposures and fewer signs and symptoms of pulpal disease than complete excavation. The rate of restoration failure in permanent teeth is also reported to be no higher after incomplete caries excavation compared to complete caries excavation. Partial excavation, followed by placement of the final restoration, has a higher success rate in maintaining pulp vitality in per-manent teeth than stepwise excavation. 25  In the present study, 48% of pediatric dentists recommended complete caries removal.The patient’s age at the time of treatment and the time interval the treated tooth was required to be in the mouth jaw had no significant effect on the success rate of the pulpectomy. It was found that in roots of successfully pulpectomized molars, resorption occurs at rates simi-lar to that of contralateral molars. In failed pulpectomies, a faster rate of root resorption was observed compared to contralateral molars. The roots of successfully pulpectomized teeth and contralateral pulpoto-mized teeth tended to resorb at equal rates. In light of concerns about the use of formocresol, more studies should be performed comparing the success rates of various pulpotomy and pulpectomy procedures, and also on non- vital primary teeth, to determine the best method of treatment. Further research is needed to determine the best me-dicament to fill primary tooth root canals, and the effect, if any, that retained zinc oxide eugenol has on the patient’s gingiva and alveolar bone. 12 Zinc oxide eugenol (ZOE) might be the most popular medicament, but its success rate varies. However, the dentists cited the ease of availability as the main reason for the selecting ZOE. Therefore, the use of ZOE might be acceptable, but the use of a combination of calcium hydroxide and iodoform, which are commercially available, should be encouraged, as both show higher success rates in the long run. 26  The present study also supported the use of this combination, which has the advantage of easy cleaning and removal, excellent anti-bacterial effect, and radiopacity. It is also available in premixed paste in a convenient syringe, which makes the root canal easily accessi-ble and prevents cross- contamination. However, for necrosed teeth, using combinations of antibacterial drugs consisting of ciprofloxacin, TABLE 6 Obturation, post- endodontic restoration, and follow up in primary teeth Material of choiceFrequency (n=306)%  χ 2 - value  P - value ZOE5417.624.163.004*Calcium hydroxide31.0Calcium hydroxide + iodoform22573.5Other247.8 Post- endodontic restoration Choice of restoration  After IPT or DPC, % (n=306)  χ 2 - value  P - valueAfter pulpotomy & pulpectomy (%)  χ 2 - value  P - value GIC28.434.529.000*3.975.842.000*Reinforced GIC or compomer22.56.9Composite resin7.82.9Full- coverage restoration(SSC)41.286.3 Post- endodontic radiographic evaluation Follow- up periodn=306%  χ 2 - value  P - value Immediate15651.050.561.000*Immediate & after 3 months13845.1Other123.9*Significant at P <.05. DPC, direct pulp capping; GIC, glass ionomer cement; IPT, indirect pulp therapy; ZOE, zinc oxide eugenol.    |  5 of 5 NAYAK ET   AL . metronidazole, and minocycline or ciprofloxacin, ornidazole, and mi-nocycline is widely accepted. 27 Most pediatric dentists consider stainless steel crowns an ideal permanent restoration after every pulp therapy. The pulp therapy leaves the treated tooth more brittle, which might subsequently frac-ture. This has led to cuspal coverage after endodontics in primary and permanent teeth. It is therefore recommended that postoperative fail-ure is prevented by placing a stainless steel crown in the first place. 28 A 2- year randomized, control trial on the restoration of primary teeth, which had undergone a pulpotomy procedure, found a non- significant difference in survival rate for teeth restored with preformed metal crowns (95%) vs a resin- modified glass ionomer/composite res-toration (92.5%). 29 Although in the present study, the pediatric dentists followed patients for 3 months for endodontically- treated primary teeth, long- term follow up is advisable to ensure that the procedure is successful and has no deleterious effects on the surrounding periodontium until it is replaced by the permanent successor. 30 Pediatric dentists render pulpal treatment to primary teeth. Technological advancements are taking place, changing the attitudes of pediatric dentists toward such treatments. These kinds of survey are helpful in assessing whether our views or approaches are in line with recent trends. It is important, because it describes the way pulp treatment for primary teeth is being rendered for pediatric dentists in India, and is in agreement with previous studies with respect to lack of consensus. That gap can be seen as an opportunity for future work in the field of pediatric dentistry. However, care has to be taken to follow the concept of minimal intervention, be more conservative, and regu-larly update ourselves by following the evidence- based dentistry and randomized, control trials, so that pulpal treatment for these children is pain free. REFERENCES  1. Nayak PA, Nayak UA, Mythili R. Effect of Manuka honey, chlorhex-idine gluconate and xylitol on the clinical levels of dental plaque. Contemp Clin Dent . 2010;1:214-217. 2. Berk H, Krakow AA. A comparison of the management of pulpal pa-thosis in deciduous and permanent teeth. Oral Surg Oral Med Oral Pathol . 1972;34:944-955.  3. Stark MM, Nicholson RJ, Soelberg KB. Direct and indirect pulp cap -ping. Dent Clin North Am . 1976;20:341-349. 4. American Academy of Paediatric Dentistry. Guideline on pulp therapy for primary and young permanent teeth. Reference Manual 2007- 08. Pediatr Dent . 2007;29:163-167. 5. Orhan AI, Oz FT, Orhan K. Pulp exposure occurrence and outcomes after 1- or 2- visit indirect pulp therapy vs complete caries removal in primary and permanent molars. Paediatr Dent . 2010;32:347-355.  6. McDonald RE, Avery DR, Dean JA. Treatment of deep caries, vital pulp exposure, and pulpless teeth. In: McDonald RE, Avery DR, eds. Dentistry for the Child and Adolescent , 7th edn. St. Louis, MO: Mosby Inc; 2000:413-419.  7. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: a crit-ical review.  J Am Dent Assoc . 2008;139:705-712.  8. 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Guideline on Pulp Therapy for Primary and Immature Permanent Teeth.  AAPD Reference Manual . 2011–12;33:212-219. 15. Su Y, Wang C, Ye L. Healing rate and post- obturation pain of single- versus multiple- visit endodontic treatment for infected root canals: a systematic review.  J Endod . 2011;37:125-132.  16. Primosch RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral paediatric dental programs in the United States. Pediatr Dent . 1997;19:118-122.  17. Feierabend SA, Matt J, Klaiber B. A comparison of conventional and new rubber dam systems in dental practice. Oper Dent . 2011;36:243-250. 18. Wolcott RB, Goodman F. A survey of rubber dam. 2. Problems in usage.  J  Am Acad Gold Foil Oper  . 1965;8:20-25 as cited from: Soldani F, Foley J. An assessment of rubber dam usage amongst specialists in paediatric dentistry practising within the UK. Int J Paediatr Dent . 2007;17:50-56. 19. Fusayama T. New concepts in operative dentistry: differentiating two lay-ers of carious dentin and using an adhesive resin . Chicago: Quintessence Pub Co; 1980. 20. Sato Y, Fusayama T. Removal of dentin by fuchsin staining.  J Dent Res . 1976;55:678-683.  21. Yip HK, Stevenson AG, Beeley JA. The specificity of caries detector dyes in cavity preparation. Br Dent J . 1994;176:417-421. 22. Banerjee A, Kidd EA, Watson TF. In vitro validation of carious dentin re-moved using different excavation criteria.  Am J Dent . 2003;16:228-230. 23. Massler M. Treatment of profound caries to prevent pulpal damage.  J Pedod . 1977;2:99-105. 24. Alaçam T. Evaluation of a tactile hardness test in indirect pulp cap-ping. Int Endod J . 1985;18:274-276. 25. AAPD Guidelines on restorative dentistry. Reference Manual . 2014/15;36:230-241. 26. Huth KC, Paschos E, Hajek-Al-Khatar N, et al. Effectiveness of 4 pulpotomy techniques—randomized controlled trial.  J Dent Res . 2005;84:1144-1148. 27. Pinky C, Shashibhushan KK, Subbareddy VV. Endodontic treatment of necrosed primary teeth using two different combinations of antibacterial drugs: an in vivo study.  J Indian Soc Pedod Prev Dent . 2011;29:121-127. 28. Duggal MS, Curzon ME. Restoration of the broken down primary molar: 2. Stainless steel crowns. Dent Update . 1989;16:71-72. 29. Atieh M. Stainless steel crown versus modified open sandwich res-torations for primary molars: a 2 year randomized clinical trial. Int J Paediatr Dent . 2008;18:325-332. 30. Moskovitz M, Yahav D, Tickotsky N, Holan G. Long- term follow up of root canal treated primary molars. Int J Paediatr Dent . 2010;20:207-213. How to cite this article:  Nayak UA, Wadhwa S, Kashyap N, Prajapati D, Mahuli AV, Sharma R. Knowledge and practice of, and attitudes toward, pulp therapy in deciduous teeth among pediatric dentists in India.  J Invest Clin Dent . 2017;e12284.
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