articol-hussein-2017
PEDODONTICS
CONTEMPORARY DENTAL CARIES MANAGEMENT CONCEPTS IN PAEDIATRIC
Original Articles
DENTISTRY: A SURVEY OF AWARENESS AND PRACTICE OF A GROUP OF GULF
COOPERATION COUNCIL DENTISTS
Iyad Hussein1a*, Manal AlHalabi1b, Mawlood Kowash1c, Amar H Khamis2d
¹Paediatric Dentistry Department, Hamdan Bin Mohammed College of Dental Medicine, Mohamed Bin Rashid University of Medicine and Health
Sciences, Dubai, UAE
²Biostatistics & Genetic Epidemiology Department, Hamdan Bin Mohammed College of Dental Medicine, Mohamed Bin Rashid University of
Medicine and Health Sciences, Dubai, UAE
a
DDS (Dam), MDentSci (Leeds), GDC Stat.Exam (London), MFDSRCPS (Glasg), UK Certified Specialist in Paediatric Dentistry, Clinical Assistant Professor
in Paediatric Dentistry
b
BDS, MSc, Associate Professor and Programme Director of Master of Science in Paediatric Dentistry Programme
c
BDS, MSc, DDSc, FRCD©, FDSRCPS(Glasg), Associate Professor in Paediatric Dentistry
d
PhD, DEA, MSc, BSc, Associate Professor Biostatistics & Genetic Epidemiology Received: January 04, 2017
Revised: February 28, 2017
Accepted: March 07, 2017
Published: March 08, 2017
Academic Editor: Rodica Luca, DDS, PhD, Professor, “Carol Davila” University of Medicine and Pharmacy Bucharest, Bucharest, Romania
Cite this article:
Hussein I, AlHalabi M, Kowash M, Khamis AH. Contemporary dental caries management concepts in paediatric dentistry: A survey of awareness and
practice of a group of Gulf Cooperation Council Dentists. Stoma Edu J. 2017;4(1):25-36.
ABSTRACT DOI: 10.25241/stomaeduj.2017.4(1).art.2
Introduction: Debatable clinically relevant child dental caries management concepts exist; restoring
a carious primary molar (RCM), the choice of pulpotomy medicament (PM), the “Hall Technique”
(HT), and sealing of dental caries (SDC). Our aim was to assess the knowledge and practice of
dentists treating children in the Gulf Cooperation Council (GCC) region of the aforementioned
contemporary concepts.
Methodology: Paediatric Dentists (PDs) and General Dental Practitioners (GDPs) who treated children
completed a questionnaire (N=150) covering: RCM choices; choice of PM; knowledge and practice
of HT and acceptance of SDC in primary and permanent teeth. Statistical analysis was conducted
using Chi-Square test (p<0.05).
Results: For RCM: 76% of those surveyed would remove non-pulpal caries in an asymptomatic lower
D and restore with composite (33%), glass ionomer or conventional stainless steel crown (SSC)
(17.4%), amalgam (7.4%) and zirconia (0.7%). The remaining 24% would seal caries (HT SSC). For
PM: 40.7% chose Ferric Sulphate, followed by Formocresol (36.7%), Mineral Trioxide Aggregate
(14%) and Calcium hydroxide (8.7%); For HT: 60.6% had knowledge of HT but 81.5% never used it.
For SDC: sealing caries in primary & permanent teeth was rejected by 56.6% & 53.1% respectively.
GDPs and PDs choices differed significantly with RCM, HT (knowledge and practice) (p=0.007, 0.003
and 0.003 respectively).
Conclusion: Overall the surveyed dentists practicing in the GCC disagreed on RCM, PM with
reluctance to accept new concepts like the HT and SDC. PDs choices of RCM differed from GDPs,
and their awareness of HT and practice of HT were more favourable.
Keywords: Hall technique, pulpotomy medicaments, dental caries, sealing caries.
1. Introduction debate, albeit a healthy one, that divided the
The discipline of paediatric dentistry is an paediatric dentistry community and created
extensive field in a constant state of development opposing schools of thought. Interestingly, the
and change. Several aspects of its clinical practice, debate had an impact on undergraduate dental
related to the management of the caries, have education and postgraduate dental practice.1
shown new insights and practices challenging In paediatric dentistry, how to restore a carious
old concepts. With the drive to base both dental primary molar (RCM),2, 3, 4 the choice of appropriate
education and dental practice on sound platforms “pulpotomy medication” (PM) in primary teeth,5 the
of evidence based dentistry and contemporary “Hall technique” (HT),6 and “sealing dental caries”
clinical guidelines, a plethora of new methods/ (SDC) in primary and permanent teeth7 were four
concepts have emerged. This created a scientific areas where change and debate took place. These
*Corresponding author:
Clinical Assistant Professor Iyad Hussein, DDS (Dam), MDentSci (Leeds), GDC Stat.Exam (London), MFDSRCPS (Glasg). Paediatric Dentistry Department, Hamdan Bin Mohammed College of Dental Medicine
Mohamed Bin Rashid University of Medical and Health Sciences, Dubai, UAE
Tel/Fax: +971 43838907, e-mail: iyad.hussein@mbru.ac.ae
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clinical issues have had direct impact upon clinical the Ethics Committee of HBMCDM (approval ERC/
Original Articles treatment of child patients and are of interest, DCDM 11/14) and approval of the event organisers
not only to specialists in paediatric dentistry, of the activities in both SoK and UAE.
but general dental practitioners alike. While the 2.4. Questionnaire
debate has been, and still is, ongoing in the dental A size A4 sheet questionnaire was designed by the
literature,8, 9 the opinions of those treating children authors and was administered to all participants
in the dental community in the Gulf Cooperation involved in the study. The questionnaire, was
Council countries (GCC) had not been assessed. piloted and tested amongst the paediatric
What were the opinions of dentists about these dentistry staff and postgraduates of HBMCDM (10
changing new concepts? As the United Arab members) (Fig. 1 and Table 1) and was found to be
Emirates (UAE) and the State of Kuwait (SoK) are reliable and consistent (Cronbach’s alpha= 0.66).
representative nations in the GCC (along with They were not included in the final sample. The
Saudi Arabia, Oman, Qatar and Bahrain) which questionnaire included:
have dental practitioners from many different - A section capturing demographic data (age,
backgrounds, the aim of this paper was to survey- gender, specialty, country of practice, years in
by means of a questionnaire- the dental awareness practice and country of qualification);
and practice of dentists in GCC countries of the - Six questions items covered the previously
above concepts. It was hypothesised that GCC highlighted topics RCM, HT, PM and SDC (Fig. 1
dentists; a) agreed on treatment options for RCM and Table 1).
when faced with a non-pulpally involved carious 2.5. Data analysis
primary molar in a cooperative child, b) agreed The survey sheets were completed anonymously.
on the PM used in a primary molar pulpotomy, c) The returned questionnaires were collected by the
were aware of the HT, d) had practiced the HT and surveyors and incomplete questionnaires were
e) agreed to the concept of SDC in primary and excluded from the study. The data collected was
permanent teeth. uploaded into a Microsoft Office 2010 Excel©
sheet and data analysis was carried out using
2. Materials and methods SPSS© statistical software Statistical Package of
2.1. Design Social Science (SPSS Inc.; Chicago, Illinois) version
The study was designed as a cross-sectional 21 was used for data management and analysis.
survey. Data was collected by the authors and Descriptive statistics including frequencies,
postgraduates (the surveyors) from Hamdan Bin means, median, and standard deviation were
Mohamed College of Dental Medicine (HBMCDM) performed to give general descriptions of the
in Dubai, UAE. The participants were dental data. Chi-square test was performed to test the
professionals (General Dental Practitioners/ dependency between variables. The level of
Interns [GDPs], and Paediatric Dentists [PDs]) statistical significance was set at 5%.
attending paediatric dentistry postgraduate
conferences held at various institutions in the 3. Results
UAE and SoK namely HBMCDM in Dubai (UAE) Out of a total of 315 attendees invited to take part
and Ras AlKhaima Dental College, Ras AlKhaima in the survey, 202 verbally expressed willingness
(UAE) and the Kuwait Health Ministry, Kuwait city, to participate and were issued the questionnaire
(SoK). The aim was to investigate their awareness sheets. However only 159 actually participated,
and practice of RCM, HT, choice of PM and SDC completed and returned the questionnaires to the
concepts outlined above. The reason behind the surveyors. Nine surveys with incomplete fields were
choice of events was to capture the views of a excluded; therefore, the total number of those
cross section of dentists dealing with children from surveyed was 150 dentists (a return rate of 74.2%).
various areas in the GCC. The demographic breakdown of those surveyed,
2.2. Sample selection was as follows: Out of the total number of those
The sample was a convenience sample selected surveyed (N=150), the majority of them were GDPs
during the aforementioned dental activities during (n=119, 79.3%) while 20.7% (n=31) were PDs. The
2015. At registration time randomised participants majority were female dentists (70.7%, n=106) and
were invited by the surveyors from HBMCDM, to the rest were males (n= 44, 29.3%).
participate in the survey by filling a questionnaire. The mean age was 30.5 (±6.5) years and the range
In both countries a total of 315 attendees were was 23-60.
invited to participate. Participants were allowed The dominant age group was between 20-30 years
to complete the questionnaire once only, thus (n= 96, 64%). The countries of practice were UAE
avoiding duplicate entries. (n=79, 52.7%) followed by Kuwait (n=35, 23.4%),
2.3. Ethical matters the remaining dentists were working out with these
All participants were informed of the objectives two countries but within the GCC [29 from Saudi
and confidential nature of the survey and that there Arabia (19.3%), 3 from Bahrain (2%), and 2 (1.3%)
would be no negative consequences for declining from each of Qatar and Oman]. The median of
to participate even if they agreed initially. Hence, years of practice was 4 years and the range was1-
they freely consented to participate in the survey. 30 years. Countries of qualification were various
Ethical approval of the work was obtained from but were regrouped into Arab countries (50.6%,
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CONTEMPORARY DENTAL CARIES MANAGEMENT CONCEPTS IN PAEDIATRIC DENTISTRY:
A SURVEY OF AWARENESS AND PRACTICE OF A GROUP OF GULF COOPERATION COUNCIL DENTISTS
Original Articles
Figure 1. The Questionnaire: original format.
Figure 2. The management choices for treatment of tooth DO caries 74 set (see radiograph inset). SSC: Stainless
Steel Crown; GIC: Glass Ionomer Cement.
n=76), East Asia (15.3%, n=23), Western Europe Glass Ionomer Cement (GIC) (n=26, 17.4%),
(11.3%, n=17), Eastern Europe (20.6%, n=31) and conventional SSC (n=26, 17.4%), amalgam (n=11,
the United States of America (USA) (2%, n=3). The 7.4%) and finally zirconia crowns (n=1, 0.7%).
results of the survey showed the following (Fig. 1 While GDPs and PDs followed the same pattern
and Table 1). (i.e., favour caries removal and restore rather than
3.1. Results for the first question (RCM), which seal), cross tabulating the RCM choices in the above
asked about management options for caries in scenario and the specialty revealed statistically
tooth #74 (class II ≤ caries shown in a radiograph) in significant differences between their individual
a cooperative six year old child (Fig. 2), the majority restorative choices (p=0.007) (Fig. 3). Most PDs
chose caries removal and restoration (n=114, 76%) (n=20, 64.5%) chose SSCs (either conventional
compared to the HT (n=36, 24%, Fig 2). Within the SSC or HT SSC) compared to GDPs (n=42, 35.3%).
group that chose to remove caries and restore, GDPs first choice was to use composite (n=42, 35.3
the choices were; composite (n=50, 33.3%), %), while PDs first choice was conventional SSCs
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Original Articles
Figure 3. First choice of management of 74 (see radiograph inset) according to specialty.* denotes statistical
significance (p >0.05). SSC: Stainless Steel Crown; GIC: Glass Ionomer Cement.
(n=12, 38.7%). Significantly so, 21.8% of GDPs statistically significant for both categories (both
(n=26) would choose GIC while all none of the PDs p values=0.003). In both the GDP and PD groups,
(n=0) chose GIC. In addition, a small proportion the majority had heard about the HT (54.6% and
of GDPs (n=11, 7.4%) and PDs (n=2, 6.5%) chose 83.8% respectively) and the majority had not
amalgam, whilst none of the GDPs (n=0) and 0.7% practiced the HT (86.5% and 61% respectively).
of PDs (n=1) suggested zirconia crowns as a final The proportion of PDs whom had heard about
restoration. the HT (n=26, 83.8%) was statistically significantly
3.2. Results for the second question (PM), the higher (p=0.003) than GDPs whom had heard of
medicament of choice in a pulpotomy (Fig 4); the HT (n=65, 54.6% of GDPs). There was a larger
overall, those surveyed chose the following: proportion of GDPs (n=103, 86.5%) who had not
Ferric Sulphate (FS) (n=61, 40.7%), followed by used the HT compared to PDs (n=19, 61.2%).
Formocresol (FC) (n=55, 36.7%), Mineral Trioxide Moreover, the proportion of PDs whom had
Aggregate (MTA) (n=21, 14%) then Calcium practiced the HT (n=12, 38.8%) was statistically
Hydroxide (CH) (n=13, 8.7%). Cross tabulating significantly higher (p=0.003) than GDPs whom
the PM choice and specialty (Fig 5) revealed no had practiced the HT (n=16, 13.5%).
statistically significant difference between PM 3.4. Results for questions 5 and 6 related to sealing
choices of PDs and GDPs (p=0.281). The majority dental caries (SDC) in primary and permanent teeth.
of GDPs chose FS (n=48, 40.3%), followed by FC The majority of those surveyed did not believe
(n=42, 35.3%), MTA (n=16, 13.4%) and finally CH that sealing in caries in primary and permanent
(n=13, 10.9%). While 41.9% of PDs (n=13) chose teeth was a viable option (Fig. 8). When asked if
FS and an equal proportion chose FC too, followed sealing in, rather than removing, caries in primary
by MTA (n=5, 16.1%). No PD chose CH as a PM teeth was a viable option the majority disagreed
medicament (n=0, 0%). (n=85, 56.6%) while 43.7% agreed (n=65).
3.3. Results for the third and fourth questions (HT), Moreover, when asked if sealing in a carious non-
t awareness and practice of the Hall Technique. cavitated enamel lesion in permanent teeth was
The majority of those surveyed (n=91, 60.6%) a viable option, the majority of those surveyed
had heard about the HT while those who had not disagreed (n=80, 53.3%) as opposed to those
heard about it were 39.4% (n=59). However an who agreed (n=70, 46.6%). When cross tabulating
overall majority (n=122, 81.4%) had not used the the specialty and the concept of SDC in primary
HT clinically, compared to 18.6% (n=28) who had and permanent teeth, no statistically significant
(Fig. 6). differences (p=0.517, p= 0.182 for both dentitions
Cross tabulating awareness and practice of respectively) between GDPs and PDs were found
the HT with specialty revealed different results (Fig. 9). GDPs opinions regarding SDC in primary
between GDPs and PDs (Fig. 7), which were teeth were divided; against (n=71, 59.6%) and
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CONTEMPORARY DENTAL CARIES MANAGEMENT CONCEPTS IN PAEDIATRIC DENTISTRY:
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for (n=48, 40.4%) and SDC in permanent teeth; 4. Discussion
Original Articles
against (n=66, 55.5%) and for (n=53, 44.5%). PDs Management of dental caries, a disease of high
opinions regarding SDC in primary teeth were prevalence in the GCC region,10 represents a
also divided; against (n=14, 45.2%) and for (n=17, challenge for those who dentally care for children,
54.8%) and SDC in permanent teeth; against whether they are GDPs or PDs.4 As dentists, we know
(n=14, 45.2%) and for (n=17, 54.8%). Therefore, that there appears to be more than one solution
there was, a tendency for both GDPs and PDs to for a said clinical problem as such, a spectrum of
have opposite views regarding SDC. PDs tended solutions exist.3 As examples for the latter, the HT,10
to accept SDC in primary teeth and permanent in addition to sealing caries in permanent teeth
teeth compared to GDPs, although this was not as an ultraconservative modality11 challenged
statistically significant. the surgical caries management model. Also,
Table 1. This table shows the overall and specific responses to the questions tabled in this study (N=150). GDP: General Dental Practitioner, PD: Paediatric Dentist.
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when a primary tooth pulpotomy is conducted, and other newer materials like Zirconia crowns.13 In
Original Articles the dilemma of the choice of the appropriate our study a majority (n=114, 76%) would follow the
medicament arises, the best of which has yet to be classical surgical doctrine and restore with various
agreed upon.5 These contemporary debates and materials, while a minority (n=36, 24%) would
concepts were the drive behind conducting this seal-in the caries. Although longevity studies have
survey in the GCC region. shown that composites14 and SSCs,12 last longer
4.1. Discussion of managing a carious primary in posterior primary teeth15 compared to GIC16
molar (RCM) no agreement between dentists exists. Our study
When dealing with a primary tooth the conventional confirmed this disagreement over which material
surgical “fill after drill” philosophy had been was considered the most appropriate for a given
accepted as the norm for decades12 although clinical situation; in this case an asymptomatic
this had been challenged and investigated4. The class II “do” carious 74 with radiographic caries
surgical approach means giving local analgesia away from the pulp in a cooperative 6 year old
(LA) to the child by injection to anaesthetise the (see x-ray inset in Figures 1, 2 and 3). It was clear
tooth, drilling the carious tissue out using a high that the majority of those surveyed favoured the
and slow speed drill, and restoring the primary conventional “drill and fill” modality compared
tooth with various restorative materials such as to the “biological modality”. The single largest
amalgam, GIC, compomers, composite, SSCs,12 group (Fig. 2) was “remove caries and restore with
Figure 4. Overall pulpotomy medication of choice for tooth 74. FC: Formocresol; FS: Ferric Sulphate; CH: calcium
hydroxide; MTA: Mineral Trioxide Aggregate.
Figure 5. Pulpotomy medication of choice for tooth 74 and specialty (GDP or PD). * FC: Formocresol; FS: Ferric
Sulphate; CH: calcium hydroxide; MTA: Mineral Trioxide Aggregate.
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CONTEMPORARY DENTAL CARIES MANAGEMENT CONCEPTS IN PAEDIATRIC DENTISTRY:
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Original Articles
Figure 6. Overall results for Hall Technique awareness and practice.
composite’ (33.3%). Although SSCs, both HT SSCs coronal pulp tissue while maintaining vital healthy
and conventional SSCs when considered together, radicular pulp. Following amputation of the coronal
would represent a larger majority (17.4%+24.2%= pulp, the remaining pulp is treated with one of the
41.8%), they were considered separately in this following medicaments19: Formocresol (FC), Ferric
study, as they represented two different modalities sulphate (FS), Mineral trioxide aggregate(MTA)
of treatment (biological Vs conventional). and Calcium hydroxide (CH). The debate about
The choice of material differed significantly which medicament to use has engaged the dental
between GDPs and PDs: GDPs tended to choose literature for a long time, subsequently affecting
composite and GIC more than PDs, while PDs the clinical decisions of PDs and GDPs alike. This
tended to choose conventional SSCs more than was indeed reflected in our study. As there was no
GDPs (p<0.05) while, interestingly, no PD chose uniform agreement on what constitutes the ideal
GIC at all. The choice of GIC for Class II lesions, PM in a given scenario (Fig. 4) and not one PM
chosen by GDPs in the case, had been previously had an outright majority. Historically, FC has been
reported to have a high failure rate.6 Moreover, the medicament of choice for the primary tooth
the choice of SSCs by most of the PDs in our study pulpotomy. Buckley in 1904 first used equal parts
was in agreement with the latest guidelines and of tricresol and formalin, although the procedures
systematic reviews that favour SSCs multi-surface and formulation have changed since Buckley’s
carious primary molars.15 first publication,20 FC has remained popular as
None of the GDPs and only one PD chose Zirconia a medicament for vital pulp therapy. Dunston
possibly because it is a newer material on the and Coll21 reported that 81% of surveyed USA
market with a lot of promise, requires extensive paediatric dentist diplomates used either diluted
crown preparation and is expensive. or full-strength FC, 18% used FS, and only 1% used
Finally, a few PDs and GDPs chose amalgam, some other medicament or technique for primary
indicating that this material is falling out of favour tooth pulpotomies. FC popularity as a pulp therapy
in the GCC region. medicament has decreased in some countries and
4.2. Discussion of the choice of pulpotomy banned in others such as the United Kingdom
medicament (PM) (UK) because of its alleged cytotoxicity, potential
The American Academy of Pediatric Dentistry mutagenicity and immune sensitization.22,23
(AAPD) suggested two treatment options for vital However, in the USA, a recent survey showed that
primary teeth with deep caries approaching the FC is still the most popular pulpotomy medicament,
pulp. These treatment options were indirect pulp despite published concerns regarding its potential
therapy (IPT) and cervical pulpotomy.17 GDPs toxicity among both GDPs and PDs.18 Despite
were more likely to attempt IPT on primary teeth the fact that the British Society of Paediatric
than paediatric dentists to treat deep caries in Dentistry (BSPD) guidelines had discouraged the
asymptomatic primary teeth.18 A primary molar use of FC19 the AAPD most recent pulp therapy
pulpotomy is defined as the clinical procedure guidelines17 recommended Buckley’s Solution
involving the removal of the inflamed and infected of FC as a pulpotomy medicament in primary
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teeth, which in the GCC region had created a lot and radiographic success rates.26 The choice of
Original Articles of confusion. This was even noted in our study; pulpotomy medicaments vary among dental
PDs used either FS or FC as a PM (equally n=13, practitioners and also between countries. A 2012
41.9% for each). MTA, FS and CH are used as USA survey18 reported that 69% of general dentists
alternatives to FC as pulpotomy medicaments.19 and 68% paediatric dentists used FC; 15% of GDPs
CH has been used, but with less long term success and 23% PDs used FS and only 3% of GDPs and 1%
because it has been shown to cause internal PDs reported using MTA. In an analysis of 47 trials
resorption in primary teeth.24 FS is a coagulative and 3910 randomised teeth, a recent Cochrane
and haemostatic agent and it has been found to systematic review in 20145 found no evidence to
have high clinical (100%) and radiographic (97%) identify a superior PM although MTA or FS were
success rates.25 Meta-analysis of six prospective highlighted as “preferable”. Smaïl-Faugeron et al,
controlled trials23 showed that both FC and FS stated4 that the “cost of MTA may preclude its clinical
had similar clinical and radiographic outcomes. use and therefore FS could be used”. This seemed
Overall clinical success of FS was 78 -100% and to be the case in our study, as the first choice by
radiographic success was 42 - 97%. MTA has also all those surveyed was FS (40.7%), followed by
been reported as a pulp therapy medicament with FC (36.7 %) but MTA came in 3rd position (14%)
very high (more than 95%) 2 year-follow up clinical followed last by CH (8.7%). It was interesting to
Figure 7. Awareness and practice of the Hall technique per specialty. *denotes statistical significance (p >0.05).
Figure 8. Sealing in caries in primary and permanent teeth. The majority of those surveyed opted for “No” in both
dentitions.
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notice in our study that, although not statistically more, when compared to GDPs (p=0.003 and
Original Articles
significant, there was a tendency for PDs to avoid p=0.003 respectively). This can be understood as
the use of CH [CH causes internal resorption19,17] the HT trials were designed and spearheaded in
and chose either FS or FC equally (thus adhering postgraduate paediatric dentistry environments29
either to the AAPD or the BSPD school of thought). and developments disseminated in specialists
Despite this, background training of those postgraduate conferences, attended mostly by
surveyed showed no clear relationship with the PDs.1 However, some of the said studies were
PM choice. Finally small proportions of GDPs and conducted in the primary dental service setting,
PDs (13.4% and 16.1% respectively) chose MTA as i.e., GDPs.6 Ideally; the ultimate aim of developing
a PM medicament. No reason can be extrapolated, the HT was for GDPs becoming the end users
however as mentioned above MTA is known to be of the HT in order to share the burden of caries
a costly material. management between GDPs and PDs. This was
4.3. Discussion of the Hall technique (HT) because most children are seen by GDPs not PDs.
The HT6,10 is a method in which an asymptomatic, It appeared that our study had shown that there is a
non- pulpally involved and aseptic carious primary large gap between knowledge and practice of the
molar lesion is managed unconventionally. The HT in this region. One can also apply conjecture
lesion is “biologically” treated by isolating it from and assume that other confounding factors, such
the oral cavity; by cementing a conventional as opposition to the HT may also play a part
SSC on the tooth with glass ionomer cement in avoidance of practice, in addition to lack of
in a child friendly play manner.27 There is no LA, appropriate hands on courses to cover the subject.
drill nor is there any tooth cutting carried out6. However, the latter points were not investigated
The first appointment involves fitting orthodontic in this study and warrant further investigation.
separators mesially and distally to the tooth Finally, it may be useful to recall the responses
intended for restoration with the HT. The second highlighted in section a) of this paper’s discussion
appointment involves removal of separators 3-5 (RCM), as less than a quarter of the respondents
days after the first appointment and selection and only, would choose the HT as a treatment modality,
cementation of the SSC with GIC by digital and in the given straight forward scenario.
patient bite pressure.10 4.4. Discussion of sealing dental caries (SDC)
There was a mixed international reaction to the The therapeutic treatment of carious lesions
development to the HT in paediatric dentistry in primary and permanent teeth by complete
circles28 with many authors supporting it29,30 and removal of caries and restoring the defective
others condemning it outright.8 In the UK, some tooth structure had classically been advocated
had gone so far as to describe it as the “Gold as the only treatment modality for many years.
Standard” for restoring the multi-surface carious When taking primary teeth into account, this was
molar.9 Our study investigated the knowledge confirmed to be the case by those surveyed in the
and practice of the HT. It showed that a majority first question in our study. On the other hand, the
of those surveyed had heard of (n=91, 60.6%) thought of SDC, especially in a permanent tooth,
but not practiced (n=122, 81.4%) the HT. The may be considered malpractice by many; however,
speciality had a significant impact on this as PDs it is now becoming acceptable that the therapeutic
were more aware of, and had practiced the HT treatment of carious lesions by complete removal
Figure 9. Sealing-in caries and specialty (GDP or PD). No statistically significant results were found between GDPs
and PDs.
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of caries and restoring the defective tooth structure there is a great need to organise continuing
Original Articles is only one of the treatment modalities used.31 dental education courses for GDPs and PDs in the
SDC in permanent teeth where the carious lesion GCC region to update them with contemporary
is partially removed or completely left has been guidelines and recommendations related to RCM,
employed as an accepted therapeutic technique PM, HT and SDC.
by some with ten year results32 and current available On a final note, ideally we would have liked the
evidence supports the SDC approach.31,33,34 There sample of PDs to be the same size of GDPs in this
are several techniques of SDC that are currently study, however, it is known that there are fewer
employed, ranging from indirect pulp capping17 specialist PDs per paediatric dental population
either by incomplete removal of caries and sealing (average 7 per 100000 in the USA) compared to
over the carious lesion closest to the pulp or by GDPs (60 per 100000 persons in the USA).39 In
stepwise caries removal where only partial removal the UK, there are 242 registered PDs, compared
of caries is employed, followed by temporary to 41,000 GDPs (personal communication,
restoration of the tooth for few months. Finally the General Dental Council, UK, 2016). Therefore,
tooth is re-entered the rest of the carious lesion, if our study sample effectively reflected the relative
any present, is removed and the final restoration proportions of the said groups in society.40
is placed.31 Another technique35 is the no caries
removal technique where the entire carious lesion 5. Conclusion
is sealed in permanent teeth as well as primary Upon surveying the opinion of a group of dentists
teeth as highlighted above in the HT section. In in the GCC region, we can conclude that there
permanent teeth, the amount of bacteria detected were disagreements amongst them in relation to
after conventional caries removal was higher than the concepts of RCM, PM, HT and SDC. They did
that which remained in sealed caries lesions.36 A not agree on treatment choices for RCM, although
systematic review and meta-analysis of incomplete the majority would surgically remove rather than
caries removal studies37 concluded that in complete seal asymptomatic non- pupal caries in a primary
caries removal appeared superior compared to molar. There was no agreement of the PM choices
complete caries excavation, especially in lesions for a primary tooth pulpotomy. The majority were
very close to the pulp. However, evidence levels aware of the HT but only a minority used it. A
are currently insufficient for definitive conclusions majority did not believe in SDC in both dentitions.
because of high risk of bias within the studies. Therefore there was a reluctance to accept new
A qualitative examination of private dentists’ concepts, such as the HT and SDC. PDs choice
treatment decisions towards non-cavitated carious of RCM significantly differed from GDPs, and their
lesions concluded that the practitioners based awareness of HT and practice of HT were more
their their decisions on their practical clinical favourable.
experience and dentists’ knowledge of the
evidence-based recommendations did not lead to Disclosure of potential conflicts of interest
higher compliance with these recommendations.38 Ethical approval: “All the procedures
In our survey, we had attempted to assess the (questionnaires) performed in this study were
opinion of the surveyed dentists regarding sealing in accordance with the ethical standards of
decay in primary and permanent teeth. It was clear Mohammed Bin Rashid University of Medicine
that the majority did not believe that SDC was a and Health Science (MBRU) and the Hamdan
viable option for both the primary and permanent Bin Mohammed College of Dental Medicine
teeth (56.6% and 53.3 %) although we specified (HBMCDM), Dubai, United Arab Emirates and
“enamel non-cavitated lesion” in the latter with the 1964 Helsinki declaration and its later
question. This indicated that there was reluctance amendments or comparable ethical standards.”
in the GCC region to accept this new concept, Informed consent: “Verbal informed consent was
and concurred with the pro “drill and fill” results obtained from all individual participants included
from the first question in this survey. Whether the in the study.”
participant was a PD or GDP had no significant Conflict of Interest: The authors declare that they
bearing on this result (p=0.517 and p=0.182), have no conflict of interest.
although there was a slight tendency for PDs to be Funding: This research did not receive any
tolerant to SDC in both dentitions. This correlated specific grant from funding agencies in the public,
in part with the result seen above with regards to commercial, or not-for-profit sectors.
the HT, in essence a method for SDC in primary
teeth.
Therefore, the hypothesis, that the surveyed GCC Authors Contributions: IH (principle author):
dentists; agreed on treatment options for RCM Concept and design of study, bulk of write up
when faced with a non-pulpally involved carious of article, editing, data gathering, analysis and
primary molar in a cooperative child, agreed on graphs. MH: Design of study, data gathering and
the PM used in a primary molar pulpotomy, had sealing caries section in article. MK: Design of
practiced the HT, and agreed to the concept of study, data gathering and pulpotomy section in
SDC in primary and permanent teeth was rejected. article. AKH: Protocol and statistical analysis and
However they were aware of the HT. Therefore, tables.
34 Stoma Edu J. 2017;4(1):25-36. http://www.stomaeduj.com
CONTEMPORARY DENTAL CARIES MANAGEMENT CONCEPTS IN PAEDIATRIC DENTISTRY:
A SURVEY OF AWARENESS AND PRACTICE OF A GROUP OF GULF COOPERATION COUNCIL DENTISTS
Acknowledgements: The authors would like Reem AlSadek for their efforts in distributing and
Original Articles
to thank the participants in this study and also collecting the questionnaires at the three venues.
Dr Eman AlNuami, Dr Ghada Hussain and Dr
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Iyad HUSSEIN
DDS (Damascus, Syria), MDentSci (Leeds, UK)
GDC Stat.Exam (London, UK), MFDSRCPS (Glasgow, UK)
Assistant Clinical Professor Paediatric Dentistry
Hamdan Bin Mohammed College of Dental Medicine (HBMCDM)
Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU)
Dubai, United Arab Emirates
CV
Dr Iyad HUSSEIN is an assistant clinical professor in paediatric dentistry at Hamdan Bin Mohammed College of
Dental Medicine (HBMCDM) at Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU),
Dubai, United Arab Emirates since 2014.
Iyad’s career spanned over 27 years as a dental surgeon in various posts in England and Scotland (Leeds
Dental Institute and Dundee Dental Hospital). Iyad qualified in 1990 from Damascus University with a
DDS. He obtained his MDentSci from Leeds University and passed the UK’s GDC statutory examination to
become a UK fully registered dental surgeon and holds the title of a UK “Specialist in Paediatric Dentistry”.
He is a Member of the Royal College of Physicians and Surgeons of Glasgow (UK). He has several scientific
publications in international and British dental journals.
Questions
The Hall technique involves
q a. Drilling a tooth;
q b. Numbing a tooth;
q c. Sealing caries with a composite;
q d. Sealing caries with a preformed metal crown.
Dentists in the GCC region carrying out pulpotomies
q a. Agree on the pulpotomy medicament;
q b. Use formocresol only;
q c. Disagree on the pulpotomy medicament;
q d. Use ferric sulphate only.
MTA in paediatric dentistry is a
q a. Pulpotomy medicament;
q b. Pulpectomy medicament;
q c. An inexpensive material widely used;
q d. A restorative material.
Of the GCC dentists surveyed in this paper
q a. 100% had used the Hall technique;
q b. 1% had used the Hall technique;
q c. 81.5% had never used the Hall technique;
q d. 100% had never heard of the Hall technique.
36 Stoma Edu J. 2017;4(1):25-36. http://www.stomaeduj.com