UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3735

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

Manejo clínico de lesões cariosas oclusais profundas por cirurgiões-dentistas brasileiros: uma pesquisa eletrônica nacional

Nayara de Oliveira SOUZA

1,2

, Diana Araújo CUNHA

, Nara Sousa RODRIGUES

, Monique Marques RIBEIRO

,

Letícia Regina Morello SARTORI

, Marcos Britto CORREA

, Flávia Pires RODRIGUES

, Vicente de Paulo Aragão SABOIA



1- Universidade Federal do Ceará, Departamento de Odontologia Restauradora, Fortaleza, CE, Brazil.

2 - Faculdade Paulo Picanço, Departamento de Odontologia Restauradora, Fortaleza, CE, Brazil.

3- Universidade de Fortaleza, Departamento de Odontologia Restauradora, Fortaleza, CE, Brazil.

4- Universidade Federal de Pelotas, Departamento de Odontologia Restauradora, Pelotas, RS, Brazil.

5- Universidade Paulista, Programa de Pós graduação em Odontologia, São Paulo, SP, Brazil.

How to cite: Souza NO, Cunha DA, Rodrigues NS, Ribeiro MM, Sartori LRM, Correa MB, et al. Deep occlusal carious lesions clinical

management by Brazilian dentists: a nationwide e-survey. Braz Dent Sci. 2023;26(4):e3735. https://doi.org/10.4322/bds.2023.e3735

ABSTRACT

Objective: To investigate the clinical management of deep occlusal carious lesions in permanent teeth by Brazilian dentists.

Material and Methods: This cross-sectional study included a sample of 732 Brazilian dentists who responded to an electronic questionnaire

composed of 20 questions addressing socio-demographic information, training and professional activity characteristics, and clinical management of

deep carious lesions. Descriptive analysis was performed, considering relative and absolute frequencies and 95% condence intervals. The association

between the dentists’ variables of interest (age group, type of higher education institution, years in practice, highest academic degree completed

and main sector of professional activity) and the mean number of incorrect answers regarding deep carious lesions management was analyzed by

Analysis of Variance (ANOVA), followed by the Bonferroni post-test (p<0.005). Results: Stepwise removal was the strategy pointed out by most

dentists (42.8%). However, 16% of the dentists selected nonselective carious tissue removal. Furthermore, 45.6% of the dentists disagreed with

maintaining carious tissue over the pulp in deep lesions with a risk of pulpal exposure. When using instruments to remove carious dentine, 17%

of the dentists chose a diamond burn while 13% preferred tungsten carbide burs. Dentists who graduated from public institutions had a lower

mean of non-conservative decisions than those from private institutions. Dentists with master’s or doctoral degrees were more conservative, as

well as dentists from public service compared to those from the private sector. Conclusion: The dissemination of conservative approaches in the

management of deep carious lesions needs to be strengthened and increasingly based on updated scientic literature.

KEYWORDS

Dental caries; Dental pulp capping; Dentists; Dentistry; Evidence-based practice.

RESUMO

Objetivo: Investigar o manejo clínico de lesões cariosas oclusais profundas em dentes permanentes por cirurgiões-dentistas brasileiros.

Material e Métodos: Este estudo transversal incluiu uma amostra de 732 dentistas brasileiros que responderam a um questionário eletrônico

composto por 20 questões abordando informações sociodemográcas, formação, características da atividade prossional e manejo clínico de

lesões cariosas profundas. Foi realizada análise descritiva, considerando frequências relativas e absolutas, e intervalos de conança de 95%.

A associação entre as variáveis de interesse (faixa etária, tipo de instituição de ensino superior, anos de prática, maior titulação acadêmica

concluída e principal setor de atividade prossional) dos cirurgiões-dentistas e a média de acertos no manejo de lesões cariosas profundas

foi analisada pela Análise de Variância (ANOVA), seguida do pós-teste de Bonferroni (p<0,005). Resultados: A remoção seletiva foi a

estratégia apontada pela maioria dos cirurgiões-dentistas (42,8%). No entanto, 16% dos dentistas selecionaram a remoção não seletiva do

tecido cariado. Além disso, 45,6% dos dentistas discordaram da manutenção de tecido cariado sobre a polpa em lesões profundas com risco de

exposição pulpar. Ao usar instrumentos para remover a dentina cariada, 17% dos dentistas escolheram uma broca diamantada, enquanto 13%

preferiram brocas de carboneto de tungstênio. Cirurgiões-dentistas formados em instituições públicas apresentaram menor média de decisões

não conservadoras do que os de instituições privadas. Os cirurgiões-dentistas com mestrado ou doutorado foram mais conservadores, assim

como os cirurgiões-dentistas do serviço público em relação aos do setor privado. Conclusão: A disseminação de abordagens conservadoras

no manejo de lesões cariosas profundas precisa ser fortalecida e cada vez mais baseada em literatura cientíca atualizada.

PALAVRAS-CHAVE

Cárie dentária; Capeamento da polpa dentária; Dentistas; Odontologia; Prática clínica baseada em evidências.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

INTRODUCTION

The removal of carious tissue is a common

procedure performed by dentists, considering that

dental caries is globally one of the main public

oral health problems [1]. Traditionally, for carious

lesions, restorative treatment has been performed

by complete and non-selective removal of carious

tissue, regardless of location and hardness.

This removal continues until sound tooth tissue

is achieved, providing a stable substrate for

subsequent restoration

. However, this strategy

used in primary or permanent teeth with deep

cavity creates a potential risk of iatrogenic pulp

exposure and other post-operative complications,

compromising tooth longevity [2,3].

Currently, the management of permanent

teeth with deep carious lesions in asymptomatic

pulps or with symptoms of reversible inammation

is based on carious tissue removal in conservative

strategies, such as stepwise removal and selective

removal, both encouraged by the International

Caries Consensus Collaboration (ICCC) [2].

Stepwise removal advocates partial removal of

carious tissue and provisional restoration followed

by remineralization-inducing materials and

complete removal in a second dental visit for the

denitive restoration [2,4]. The initial procedure

aims to provide a favourable environment for the

dentin-pulpal complex physiological reactions

that provide the formation of tertiary dentin and

remineralization of the lesion before the complete

excavation of the carious tissue, avoiding a

possible pulpal exposure [2,3]. Therefore, selective

removal of carious tissue supports the restricted

removal of superficial, necrotic, disorganized

carious tissue, with demineralized dentine

remaining on the pulpal wall [2]. A frequent

concern of dentists about this technique is the

presence of residual bacteria in the cavity after

the denitive restoration [5,6]. Nevertheless, there

is no need to perform a complete elimination of

microorganisms during cavity preparation given

that the restorations are properly sealed [2].

Although new concepts and recommendations

have been developed, neither knowledge

reach dentists nor they do not practice this

knowledge in their offices [7,8]. This lack of

knowledge or interest can be perceived in previous

questionnaire surveys that have shown a wide

variation in strategies of carious tissue removal

in primary or permanent teeth among dentists

worldwide [8,9,10,11]. Brazilian studies regarding

the clinical management of deep carious lesions

in both dentitions have been conducted only

in small and local samples [5,7,8,12]. For this

reason, it would be of great interest to know

how deep knowledge of the criteria, strategies,

and methods of caries removal are established in

the clinical practice of Brazilian dentists. Thus, if

necessary, best practices would be recommended

regarding the uniformity of the clinical procedures.

Therefore, the present study investigated the

knowledge and clinical management of dentists

from different regions of the country regarding

deep occlusal carious lesions in permanent teeth.

MATERIAL AND METHODS

Study design and ethical issues

The present observational, cross-sectional,

descriptive, and quantitative study was developed

using an online questionnaire applied to Brazilian

dentists from October to December 2020. This study

was approved by the Research Ethics Committee

of the Universidade Federal do Ceará, Brazil on

September 15, 2020 (protocol #4.277.387). Before

the questionnaire application, all participants

agreed to the Consent Form displayed on the

rst page of the online form, which guaranteed

the confidentiality of the data and personal

information collected.

Questionnaire development and pre-survey

The questionnaire was developed by a

group of restorative dentistry specialists, based

on information obtained from the previous

studies [2,8,9], as well as additional relevant

questions about the topic. During the development

of the instrument, a pre-test was conducted within

one week with 10 dentists not previously involved

with the study, aiming to verify the clarity and

objectivity of the questions, gauge the reliability

of the instrument to data collection, as well as

to determine the average time to complete the

form. The pre-survey questionnaire was hosted

in the Google Forms® (Google Corp., USA)

platform and the link was sent to pre-survey

participants by e-mail. Furthermore, based on

the answers, small adjustments were made to

adapt the questionnaire, considering the inclusion

of a description of technical terms about the

management of deep carious lesions that worked

like a glossary. The average preview time to

complete the pre-survey form was 9 minutes.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

Questionnaire content, sample size, and survey

application

After the pre-survey procedures, the final

questionnaire consisted of 20 mandatory close-ended

questions distributed in four blocks: (1) socio-

demographic variables (sex, age, Brazilian regional

division – states/macroregion, and main sector of

professional activity) and training and professional

activity characteristics (type of higher education

institutions, years in practice, highest academic

degree completed, dental specialty and service

provision); (2) deep carious lesion treatment

(criteria, strategies, and methods for deep carious

tissue removal); (3) materials for protecting the

pulp-dentin complex (with and without pulp

exposure); (4) concepts regarding deep carious

lesions (permanence of residual microorganisms

from cavity preparation, maintenance of remaining

demineralized dentine, and cavity sealing).

The target population for this study was

Brazilian dentists, who numbered approximately

330,000 in 2020 (data provided by the Federal

Council, 2022). The sample size calculation was

performed in the OpenEpi Menu, web version

3.01, available online at www.OpenEpi.com.

Considering the variables of interest with an

unknown prevalence of 50%, a margin of error of

5 percentage points, and a 95% condence interval,

a sample size of 384 dentists was estimated.

The nal questionnaire was hosted in the

Google Forms® (Google Corp., USA) online

platform. The participants received a link sent

via e-mail and social networks - WhatsApp®

(WhatsApp LLC, Meta Inc., USA), Facebook®

(Meta Inc., USA), and Instagram® (Kevin Systrom,

Mike Krieger, Burbn, Inc., USA). The dissemination

of the link to the survey and other information was

done using a prole specially developed for the

survey on Instagram® (@questcarie). There were

no nancial or material incentives for participation

in the research. All participants were volunteers.

The answers were collected between October 3

2020 and December 3

, 2020. At the end of the

questionnaire, the participants could enter their

contact e-mail in a specic eld if they desired

to receive the answers to questions about the

management of deep carious lesions. After the

data collection period, a le with the answer key

and comments on questions of blocks 2, 3 and 4,

according to current scientic evidence, was sent

to the dentist via e-mail using the research account

(questionariocarie@gmail.com).

Data management and analysis

After the data collection period, data

was imported into a Microsoft Excel 2016

(Excel 2016, Microsoft, Richmond, USA)

spreadsheet. To improve data presentation the

state of professional activity was categorized

into Brazilian macroregions. For the variable

age group, the categories “50 to 59 years old”

and “60 years old or above” were grouped into

“≥50 years old”. Also, the variables years in

practice and highest academic degree completed,

respectively question 5 and 6, had their categories

grouped, as presented in the results. For question

4 – The type of higher education institution

had its categories “Community” and “Public”

grouped into “Public” category and question

8 - The main sector of professional activity

had grouped the categories “Private dental

clinic” and “Private dental clinics network”

into “Dentist- Private sector” and the category

“Graduate program dental clinic” grouped with

“Teaching”. Finally, question 16 – Management

of minor pulpal exposure (pinpoint exposure)

with bleeding in deep carious lesions, had the

answer alternatives “I do not apply the material,

I perform pulpotomy” and “I do not apply

material, I perform pulpectomy” grouped into

“Pulpotomy or Pulpectomy”.

All statistical analysis was performed using

Stata®, version 14.2 (Stata Corp. College

Station, TX, USA) software. For all variable

missing data was treated as a loss of information

and excluded from the analysis. Descriptive

analysis was performed to assess frequencies

of categorical variables and 95% confidence

intervals. To assess the association between a

dentist´s characteristics and level of knowledge

about conservative management of dental caries

a quantitative variable was created based on

9 questions (from questions 9 to 12 and 14 to 19).

For each incorrect answer to the question, a point

was attributed to the scale variable. This variable

named “non-conservative” was used to evaluate

the degree of responses considered incorrect

concerning the current recommendations for

the treatment of deep carious lesions. Thus,

the questionnaire score corresponded from 0-9,

where lower values corresponding to more

conservative decisions. Data distribution of the

“non-conservative” variable was verified by

Bartlett’s Test, followed by Analysis of Variance

(ANOVA) and Bonferroni’s Test (p<0.05).

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

RESULTS

Sample characteristics

A total of 732 dentists participated in this

e-survey. The socio-demographic, training and

professional activity characteristics of the dentists

are presented in Table I. Females were predominant

in the sample (70.1%), as well as dentists in young

adulthood (20 to 29 years old – 41.4%), trained

in public institutions of higher education, and

with more than 5 years in practice. Approximately

30% of the sample had only an undergraduate

degree in Dentistry, completed until the research

period. Regarding professional activity, most of

the participants worked as a dentist in the private

sector (65.7%). The highest number of answers

was obtained in the Northeast region of the country

(39.8%), followed by the Southeast (37.3%).

Criteria for tissue removal in deep carious

lesions

Table II presents the responses of the study

participants regarding the criteria used for the

removal of carious tissue on the pulpal wall of

deep lesions. The colour was not considered

a relevant criterion by 57.4% of the dentists

though 12.4% of the dentists reported removing

darkened dentine close to the pulp. Considering

the hardness of the remaining dentine, 56.8% of

the dentists used to excavate softened carious

tissue, 28.4% remove dentin with a leathery

aspect, and 3% did not use this criterion.

Table I - Absolute frequencies (n), relative frequencies (%), and 95% conﬁdence intervals (95%CI) of the socio-demographic, training, and

professional activity characteristics of Brazilian dentists (n=732)

Variable n % 95% CI

Sex

Female 512 70.1 66.7 to 73.3

Male 218 29.9 26.6 to 33.3

Type of higher education institution

Private 349 47.7 44.1 to 51.3

Public 383 52.3 48.7 to 56.0

Years in practice

≤ 5 years 345 47.3 43.6 to 50.9

6 to 10 years 135 18.5 15.8 to 21.5

11 to 20 years 120 16.4 13.9 to 19.3

>20 years 130 17.8 15.1 to 20.8

Age group

20 to 29 years old 303 41.4 37.9 to 45.0

30 to 39 years old 244 33.3 30.0 to 36.8

40 to 49 years old 103 14.1 11.7 to 16.8

≥50 years old 82 11.2 9.1 to 13.8

Highest academic degree completed

Undergraduate degree in dentistry 226 30.9 27.6 to 34.3

Residency or advanced special training (certiﬁcation) 327 44.7 41.1 to 48.3

Master’s or Doctorate degrees 179 24.4 21.5 to 27.7

Main sector of professional activity

Dentist – Private sector 468 65.7 62.1 to 69.0

Dentist – Public sector 200 28.0 24.9 to 31.5

Teaching 45 6.3 4.7 to 8.3

Brazilian regional division

Southeast 273 37.3 33.8 to 40.9

Northeast 291 39.8 36.3 to 43.3

South 129 17.6 15.0 to 20.6

Central-West 16 2.2 1.3 to 3.5

North 23 3.1 2.1 to 4.7

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

About half of dentists do not consider moisture

as a parameter for dentine tissue removal. On the

other hand, 8% reported removing dry dentine.

Strategies and methods for carious tissue

removal and materials to protect the

dentin-pulp complex

Stepwise removal was the strategy used

for most of the dentist (42.8%), followed by

the selective removal of remaining dentine

(Table III). On the other hand, a significant

percentage of dentists (16.1%) still perform

nonselective removal (Table III). According to the

dentists, the decision for or against a strategy was

based on clinical practice guidelines, scientic

evidence, and familiarity/ease of the procedure.

The use of hand instruments combined or not

with tungsten carbide burs was the most cited

tool for excavation of carious dentin (Table III).

After the removal of carious tissue in deep

lesions, about 35% of dentists reported performing

only cavity-lining followed by restorative material

and 7.9% reported applying the adhesive directly

into the dentine (Table III). In the case of pinpoint

pulpal exposure during excavation, direct pulpal

capping was preferred over pulpotomy and

pulpectomy (Table III). For direct pulpal capping,

81.6% of the dentists reported that they used

calcium hydroxide-based powder and cement

materials (Table III).

Concepts about carious tissue removal in

deep lesions

Table IV presents the dentists’ responses

regarding the concepts related to deep lesions.

The majority of participants (64.3%) disagree or

strongly disagree that caries-related microorganisms

should be completely removed during the cavity

preparation, as the residual bacteria may form

a new carious lesion. In addition, most of the

participants (74.6%) agreed or strongly agreed that

residual microorganisms from cavity preparation

can be left in it because well-sealed restorations

block the carbohydrate supply to bacteria, which

stops lesion progression. However, about 20% of

dentists responded to these statements incorrectly.

Moreover, almost half of the dentists (45.6%)

disapproved maintenance of carious tissue near the

pulp to avoid pulpal exposure.

Association between dentists’ socio-demographic

characteristics and the mean of “non-conservative”

responses

No statistically significant association

was found between years in practice and the

mean number of answers considered incorrect

(p=0.128), based on the current scientific

knowledge (Table V). Dentists who graduated

from public institutions had a lower mean of

non-conservative responses than those who

graduated from private schools (p<0.001).

Table II - Absolute frequencies (n), relative frequencies (%), and 95% conﬁdence intervals (95% CI) for variables related to the criterion for

tissue removal in deep carious lesions (n=732)

Variable n % 95%CI

Color of remaining dentine

Did not use color as a criterion 420 57.4 53.7 to 60.9

Pale/Yellow dentine 221 30.2 27.0 to 33.6

Dark/Brown/Black dentine 91 12.4 10.2 to 15.0

Hardness of remaining dentine

Did not use hardness as a criterion 22 3.0 2.0 to 4.5

Soft dentine 416 56.8 53.2 to 60.4

Leathery/Firm dentine 208 28.4 25.2 to 31.8

Hard dentine 86 11.8 9.6 to 14.3

Moisture of remaining dentine

Did not use moisture as a criterion 374 51.1 47.5 to 54.7

Wet dentine 209 28.5 25.4 to 32.0

Moist dentine 89 12.2 10.0 to 14.7

Dry dentine 60 8.2 6.4 to 10.4

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

Table III - Absolute frequencies (n), relative frequencies (%), and 95% conﬁdence intervals (95%CI) for variables related to strategies and

methods for carious tissue removal, and pulp protection materials used for deep carious lesions (n=732)

Variable n % 95%CI

Strategies for carious tissue removal

Stepwise removal of carious tissue 313 42.8 39.2 to 46.4

Selective removal of carious tissue 254 34.7 31.3 to 38.2

Nonselective removal of carious tissue 118 16.1 13.6 to 19.0

Other 47 6.4 4.8 to 8.4

Methods for carious tissue removal

Hand excavators 359 49.1 45.5 to 52.7

Tungsten carbide burs 100 13.7 11.4 to 16.4

Hand excavators + Tungsten carbide burns 148 20.2 17.5 to 23.3

Diamond burs 124 17.0 14.4 to 19.9

Most used pulp protection material in deep carious lesions without pulpal exposure

(considering resin composite as restorative material)

Only cavity-lining material 258 35.2 31.8 to 38.8

Only cavity base material 100 13.7 11.3 to 16.3

Cavity-lining material + Cavity base material 316 43.2 39.6 to 46.8

Did not use, applies the adhesive directly into the dentine 58 7.9 6.2 to 10.1

Management of minor pulpal exposure (pinpoint exposure) with bleeding in deep carious lesions

Using calcium hydroxide powder 169 23.1 20.2 to 26.3

Using calcium hydroxide paste 81 11.1 9.0 to 13.5

Using calcium hydroxide cement 35 4.8 3.4 to 6.6

Using calcium hydroxide powder + calcium hydroxide cement 258 35.2 31.8 to 38.8

Using calcium hydroxide paste + calcium hydroxide cement 54 7.4 5.7 to 9.5

Using Mineral Trioxide Aggregate (MTA) 26 3.5 2.4 to 5.2

Pulpotomy or Pulpectomy 109 14.9 12.5 to 17.7

Table IV - Absolute (n) frequencies, relative (%) frequencies, and 95% conﬁdence intervals (95%CI) for variables related to concepts about

carious tissue removal in deep carious lesions (n=732)

Variable N % 95% CI

“Caries-related microorganisms should be removed completely during cavity preparation, because the permanence

of residual bacteria may form a new carious lesion.”

Strongly disagree 253 35.2 31.2 to 38.8

Disagree 209 29.1 25.8 to 32.5

Neither agree nor disagree 32 4.4 3.2 to 6.2

Agree 159 22.1 19.2 to 25.3

Strongly agree 66 9.2 7.3 to 11.5

“Residual microorganisms from the cavity preparation can be left in the cavity because well-sealed restorations

block the carbohydrate supply to the bacteria, which interrupts carious lesion progression.”

Strongly disagree 51 7.2 5.6 to 9.4

Disagree 84 12 9.8 to 14.6

Neither agree nor disagree 43 6.1 4.6 to 8.2

Agree 240 34.2 30.8 to 37.8

Strongly agree 283 40.4 36.8 to 44.0

“The carious tissue near the pulp should not be removed in order to avoid pulpal exposure.”

Strongly disagree 152 20.9 18.1 to 24.0

Disagree 180 24.7 21.7 to 28.0

Neither agree nor disagree 32 4.4 3.1 to 6.1

Agree 255 35.0 31.6 to 38.6

Strongly agree 109 15.0 12.5 to 17.8

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Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

Also, dentists with post-graduate studies had

more conservative responses (p<0.001), as well

as those who work in the public dental service

than their counterparts (p<0.001) (Table V).

DISCUSSION

The clinical management of deep carious

lesions as well as changes in its paradigm have

been discussed in several countries [2,3,13,14].

The present study showed that most Brazilian

dentists decide on stepwise removal in cavities

involving the inner third of the dentine. This

result corroborates with Sales et al. (2020) [8]

and diverges from the ndings of Weber et al.

(2011) [5], both conducted in South Brazil.

The latter reported that most dentists (71%)

performed complete and nonselective carious

tissue removal in permanent teeth and only 17%

preferred stepwise removal. This divergence

of results between studies is probably due to

time. In the last years, less invasive dental

procedures have been encouraged to be used by

dentists. More invasive approaches in primary or

permanent teeth were also reported in studies

conducted in Norway and Germany [6,15].

The lack of a consensus regarding the depth of

excavation, strategies and appropriate diagnostic

criteria for caries removal may have favoured

non-conservative practices in the recent past as

observed in the aforementioned studies. However,

in 2016, a set of clinical recommendations (ICCC)

on the management of deep carious lesions in

both dentitions was developed, discouraging its

complete removal, which may have favoured

changes in clinical practices [2,16].

In the present study, almost half of the

dentists reported that they do not keep the carious

tissue close to the pulp, which may have been

reected in the choice of strategy of carious tissue

removal. Although selective removal presents a

lower risk of pulpal exposure when compared

to stepwise removal, only 34.7% of the dentists

point out it. Indeed, dentists are afraid that

the remaining carious tissue into the denitive

restoration - advocated in the selective removal

of carious tissue - could cause postoperative pain,

caries progression, and restorative failure [2,9].

However, there is no scientic evidence correlating

the permanence of residual carious tissue with

Table V - Association between socio-demographic, training, and professional activity characteristics of Brazilian dentists and the mean number

of incorrect answers regarding the management of carious tissue removal in deep lesions. One-way ANOVA

Variable Mean ± SD

p-value

Age group

20 to 29 years old 4.76±1.56

0.688

30 to 39 years old 4.77±1.62

40 to 49 years old 4.97±1.56

≥50 years old 4.76±1.43

Type of higher education institution

Public 4.48±1.48

<0.001

Private 5.13±1.59

Years in practice

≤ 5 years 4.76±1.56

0.128

6 to 10 years 4.68±1.62

11 to 20 years 5.09±1.62

< 20 years 4.68±1.45

Highest academic degree completed

Undergraduate degree in dentistry 4.78±1.50

<0.001

Residency or advanced special training (certiﬁcation) 5.06±1.54

Master’s or Doctorate degrees 4.32±1.59

Main sector of professional activity

Dentist – Public sector 4.48±1.48

<0.001Dentist – Private sector 5.00±1.57

Teaching 3.84±1.36

Note: Diﬀerent lower-case letters represent statistically signiﬁcant diﬀerence between groups (p<0.05).

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

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Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

postoperative complications [2]. Selective

removal seems to be more advantageous because

it is not necessary reopening the cavity, avoiding

the possibility of pulpal damage and reducing

clinical time and treatment costs [2,17].

It is important to note that there are limitations

in the present study. Firstly, the sample was dened

according to the availability of the participant,

thus being considered a convenience sample.

Thus, selection bias can be present in our results.

Randomized recruitment of participants would

better reect the knowledge, attitudes and practices

about the clinical management of deep carious

lesions. Secondly, the questionnaire was not

submitted to a previously protocolled validation

process, however, a rigorous pre-testing process,

described before, was carried out, besides having

a language adapted to the routine of the Brazilian

dentist. Finally, it is worth mentioning that this study

was performed during the COVID-19 pandemic. The

use of instruments with aerosols was discouraged

due to the risk of the spread of the virus. Therefore,

it is possible that more conservative approaches

were elected by dentists also due to the reects of

the pandemic in dental practice.

When using instruments and methods to

remove carious dentine, 17% of dentists decided

for diamond burs while 13% preferred tungsten

carbide bur. Currently, there are several methods

available for removing carious tissue such as

dentine excavators, and metallic polymeric,

tungsten carbide, and ceramic burs, air dental

abrasion, ultrasonic abrasion, chemical-mechanical

method and lasers [2]. The diamond burn is not

recommended, as it is ineffective in cutting

softened carious tissue. During cavity preparation,

its use should be employed to open the cavity

accessing the carious lesion [18].

Pulp exposure is a critical point that can

result in an unfavourable prognosis [19,20].

For this reason, calcium hydroxide and mineral

trioxide material (MTA)-based products are

indicated in cases of direct pulp capping in

permanent teeth [21]. In the present study,

most dentists (81.6%) decided for one of the

presentation forms of calcium hydroxide, probably

due to the tradition of its use in educational

institutions, its low cost, and its ease of application.

However, the mineral barrier produced by the

calcium hydroxide is porous and does not adhere

to the pulp wall, thus generating an inefcient

sealing. Moreover, the high solubility generates

its dissolution over time, causing spaces between

the tertiary dentin and the restorative material

that can be easily populated by microorganisms

(tunnel defects) [22]. On the other hand, MTA

produces a more homogeneous and continuous

mineralized barrier, achieving an efcient pulp

seal [22,23]. Despite presenting better results,

MTA was chosen as a pulp capping material by

only 3.5% of the dentists and the main reason for

this is probably due to its high cost for most of

Brazilian dentists. Besides, this material has been

developed during the last twenty years which

can be considered little time compared calcium

hydroxide that has been used as a pulp-capping

agent for over ninety years and is widespread

worldwide. Thus, dentists may not be aware of

the promising results of MTA.

More conservative approaches were preferred

over invasive treatment in case of pulpal exposure

during carious tissue removal. Nonetheless, 14.9%

of dentists indicate pulpotomy or pulpectomy in

the management of minor pulpal exposure. These

ndings are a source of concern, as according to the

European Society of Endodontics statement, invasive

procedures that compromise pulp vitality result in

tooth loss and elevated treatment costs [21,24].

Previous studies suggest that residual bacteria

in properly sealed cavities are deprived of nutrients

essential for their survival, which stops lesion

progression [2,17,25]. However, approximately

half of French, German, and Norwegian dentists

disagreed with the permanency of bacteria under

restorations fearing a continuity of the lesion and

loss of pulp vitality [2]. In the present study, most

dentists agreed that residual microorganisms

from cavity preparation can remain intothe

cavity, which suggests that Brazilian dentists

seem to have more conservative decision-making

than Europeans regarding caries tissue removal

daily in-ofce protocols

Dentists with post-graduate degrees as well

as those from public institutions decided for more

conservative approaches. Dentists involved in

scientic research tend to follow the scientic

literature up more frequently [26]. Brazilian

public universities have been responsible for

about 95% of Brazil’s scientic development and

this research activity may inuence students to

follow the current approaches [27]. Similarly,

dentists working in the public sector were more

conservative than those in the private sector,

probably due to the collaboration between health

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3735

Souza NO et al.

Deep occlusal carious lesions clinical management by Br azilian dentists: a nationwide e-survey

Souza NO et al.

Deep occlusal carious lesions clinical management by Brazilian dentists:

a nationwide e-survey

agenciesand higher education institutions, in

promoting training and refresher courses for

dentists working in the Brazilian Public Health

System (SUS - acronym in Portuguese) [28].

Another aspect is that in public services dentists

feel free to choose treatment, with less market

pressure, which can favour choices for conservative

treatments. In the same way, access to endodontic

treatment in public services in Brazil exists but

is restricted, so conservative strategies may

be adopted by dentists to avoid the need for

treatments of high complexity.

Considering the size of Brazil and its

population and diversity, this is important to

highlight that this study is the rst research with

participants from all six Brazilian regions, which

makes it extremely relevant to guide educational

sectors and actions regarding the current and

future Brazilian dentists. At the end of this study,

it is clear that the management of deep carious

lesions is still controversial among dentists and

its theoretical basis is to be widely employed in

practice to promote a paradigm change. As the

main contribution from this study to future public

policies in Dentistry, it is necessary to emphasize

the importance of sending the key answer and

commentaries based on the updated literature

back to the participants, as performed in this

study. It is believed that these questions may lead

dentists, even the most sceptical, to reect on the

topic and make a change in their daily practice.

The questionnaire can be validated in the future

and used as a xed instrument to evaluate the topic

in Brazil and in other nations worldwide.

CONCLUSION

In summary, it can be concluded that most

of dentists is not aware of the minimally invasive

dentistry concepts that represents a drastic

change of paradigm and it can take a considerable

long time to incorporate those changes into their

clinical daily practice. To achieve this goal, the

dissemination of more conservative approaches

regarding the management of deep carious

lesions needs to be strengthened and increased,

based on the updated scientic literature.

Acknowledgements

The authors would like to express their

gratitude to the study participants for their time

and dedication to taking part in this study.

Author’s Contributions

NOS: Writing – Original Draft Preparation,

Methodology. DAC: Methodology. NSR:

Conceptualization. MMR: Software. LRMS:

Writing – Review & Editing. MBC: Data Curation.

FPR: Supervision. VPAS: Project Administration,

Funding Acquisition.

Conict of Interest

No conicts of interest declared concerning

the publication of this article.

Funding

This work was financially supported by

Coordenação de Aperfeiçoamento de Pessoal

de Nível Superior (CAPES) [grant numbers

88882.454131/2019-01].

Regulatory Statement

The study was conducted in accordance with

all the provisions of the local human subject’s

oversight committee guidelines and policies of

Research Ethics Committee of the Universidade

Federal do Ceará, Brazil. The approval code for

this study is: 4.277.387.

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Vicente de Paulo Aragão Saboia

(Corresponding address)

Universidade Federal do Ceará, Departamento de Odontologia Restauradora,

Fortaleza, CE, Brazil

Email: vpsaboia@yahoo.com

Date submitted: 2022 Dec 10

Accept submission: 2023 Oct 14