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ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 83-87

The knowledge about vital pulp therapy of permanent teeth among Saudi internship dentists and dental students


1 Department of Restorative Dental Sciences, Alfarabi Colleges of Dentistry and Nursing, Riyadh, Saudi Arabia
2 Department of Dental Intern, Aljouf University, Buraydah, Saudi Arabia
3 Department of Restorative Dental Sciences, Dar Aluloom University, Buraydah, Saudi Arabia
4 Department of Dental Intern, Almajmaah University, Buraydah, Saudi Arabia
5 Department of Restorative Dental Sciences, Buraydah Colleges, College of Dentistry, Buraydah, Saudi Arabia

Date of Submission24-May-2019
Date of Decision17-Jun-2019
Date of Acceptance25-Jun-2019
Date of Web Publication23-Apr-2020

Correspondence Address:
Dr. Mazen Doumani
Department of Restorative Dental Sciences, Alfarabi Colleges of Dentistry and Nursing, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_84_19

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  Abstract 

Introduction: The aim of this study was to assess the knowledge of Saudi internship dentists and dental students about the different types of vital pulp therapy (VPT) of permanent teeth.
Materials and Methods: A comprehensive survey regarding different types of VPT were distributed either by E-mail or hard copies to internship dentists and clinical levels of dental students at seven different dental schools in Saudi Arabia. Descriptive statistics and Chi-square test were used to analyze the responses to the questions.
Results: A total of 363 participants were included in this survey: 69.4% were male, and 30.6% were female. 27.3% of participants were internship dentists. About 74.4% of the participants believe that cone-beam computed tomography provides more accurate information about the root formation compared to conventional radiographs. About 44.4% of participants did not agree that sodium hypochlorite serves as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis and to help determine whether to proceed with partial pulpotomy, complete pulpotomy, or pulpectomy. 33.3% did not know that if mineral trioxide aggregate is substituted for calcium hydroxide in VPT procedures, similar time periods for apical maturation can be anticipated. There was no significant statistical difference among all examined groups regarding to knowledge and awareness about VPT.
Conclusion: Within the limitations of this survey-based investigation among internship dentists and clinical levels' dental students, it was concluded that the participants had average knowledge about the different types and steps of VPT.

Keywords: Apexification, apexogenesis, direct pulp capping, immature, mineral trioxide aggregate, pulpotomy


How to cite this article:
Doumani M, Almutairi ST, Talal Alshammari NT, Alshami AN, Alharbi AS, Habib A. The knowledge about vital pulp therapy of permanent teeth among Saudi internship dentists and dental students. Saudi Endod J 2020;10:83-7

How to cite this URL:
Doumani M, Almutairi ST, Talal Alshammari NT, Alshami AN, Alharbi AS, Habib A. The knowledge about vital pulp therapy of permanent teeth among Saudi internship dentists and dental students. Saudi Endod J [serial online] 2020 [cited 2020 Aug 5];10:83-7. Available from: http://www.saudiendodj.com/text.asp?2020/10/2/83/283143


  Introduction Top


As the pulp is important for tooth nutrition, innervations, and immunocompetency,[1] the maintaining of this precious tissue increases a tooth' mechanical resistance and survival rate.[2] Vital pulp therapy (VPT) is performed in cases of trauma, caries, and restorative procedures to preserve the vital pulp tissue.[3] VPT is a wide term including indirect pulp capping, direct pulp capping, pulp debridement, pulpotomy, and apexogenesis.[4] It is considered very important before starting VPT to obtain a pulpal and periapical diagnosis to know how to deal with the dental pulp especially in case of pulp exposure presence. A study found that when a caries lesion reached pulp that is diagnosed as normal or with reversible pulpitis, only the pulpal tissue adjacent to the caries showed signs of inflammation. Therefore, the clinician can treat the carious exposed or indirect exposed pulp tissue in case of deep caries with a pulp cap or pulpotomy.[5] Traumatic pulp exposures have a better prognosis than mechanical exposures during caries excavation or carious exposures due to the reduced infection risk. If pretreatment pulpal diagnosis is necrotic or irreversible pulpitis, conventional endodontic treatment is indicated. The periapical diagnosis of normal periapical area, no pain on percussion and palpation, no presence of deep periodontal pockets, no mobility, is viable to VPT if there is no other evidence of necrotic pulp. After caries removal, an exposed or indirectly exposed pulp should be irrigated with 17% (ethylenediaminetetraacetic acid) solution for 1 min.[6],[7] It has been recommended in the literature to use sodium hypochlorite (NaOCl) to control pulpal hemorrhage because this material has advantages of possessing antibacterial properties and providing enhanced hemorrhage control.[8] Several materials have been suggested to use in VPT as calcium hydroxide (Ca(OH)2), mineral trioxide aggregate (MTA), bone morphogenetic proteins and transforming growth factor-β, enamel matrix derivative, propolis, calcium-enriched mixture cement, tricalcium phosphate cement, and some other bioactive materials.[9] Nowadays, bioceramics are materials of choice in VPT, in spite of the long period use of Ca(OH)2, because MTA (a bioceramic material) overcame Ca(OH)2 high solubility, causing pulp necrosis in direct pulp capping, and the low mechanical resistance. Furthermore, bioceramics are able to form Ca(OH)2 and hydroxyapatite.[10] In addition, MTA showed clinical and radiographic success as a pulpotomy agent in immature permanent teeth (apexogenesis) and seems to be a suitable alternative to Ca(OH)2 since MTA has demonstrated a superior ability to maintain the integrity of pulp tissue and produces a thicker and less porous dentinal bridge at a faster rate.[11],[12]

Skill and knowledge are the keys to treatment success and as the surveys are an indicator of the knowledge and awareness level of dental student or dentists so this study aimed to assess the knowledge of Saudi internship dentists and clinical levels of dental students about the VPT of permanent teeth.


  Materials and Methods Top


The questionnaire used in current study was randomly mailed (as soft copy) and given out by hand (as hard copies) to 500 participants of the internship dentists and clinical levels' dental students in different Saudi academic centers; Almajmaah University, Dar Al Uloom University, AlFarabi in Jeddah College, AlFarabi in Riyadh College, Aljouf University, King Saud University, and Riyadh Elm University. We received only 363 responses in both types of the questionnaire with a response rate of 72.6%. The questionnaire comprised two main parts. The first part of the questionnaire included demographic and general information as the university name, gender, and academic level. While the second part contained 17 questions about some different aspects of diagnosis, the different types of VPT, and some materials used in VPT. Approval from the Ethics Committee of Alfarabi Colleges of Dentistry and Nursing, Riyadh, Saudi Arabia, was obtained (#00334/2018). The data collected were analyzed using descriptive statistics (SPSS 25.0 for Windows; SPSS, Inc., Chicago, IL, USA) and Chi-square test at P = 0.05.


  Results Top


After data collecting and analyzing, the following results were obtained:

A total of 363 questionnaires regarding the VPT of permanent teeth were completed as follows: Almajmaah University (n = 54; 14.9%), Dar Al Uloom (n = 22; 6.1%), Alfarabi College/Jeddah (n = 30; 8.3%), Alfarabi College/Riyadh (n = 146; 40.2%), Aljouf University (n = 51; 14%), King Saud University (n = 20; 5.5%), and Riyadh Elm university (n = 40; 11%). A total of 252 (69.4%) of the respondents were male, while 111 (30.6%) were female. The participants were according to the academic level as follows: Level 8 (20.9%), Level 9 (16.5%), Level 10 (11.6%), Level 11 (11.8%), Level 12 (11.8%), and internship (27.3%).

The result of this survey revealed that just 16.5% of participants know that the closure of root apex is completed approximately 2–3 years after tooth eruption and 14.6% of participants know that the use of cone-beam computed tomography (CBCT) provides more accurate information about the root formation compared to conventional radiographs. 17.6% of participants said that the drawbacks of Ca(OH)2 include weak marginal adaptation to dentin, and dissolution over time while 12.9% of participants said that the unique physiochemical properties of MTA promote a superior environment for pulpal repair and bridge formation compared to Ca (OH)2 products. The results of this study showed that 18.7% of participants realize that successful outcomes for VPT decrease as the patient's age increases. Moreover, there was a lack of correct answer in the two academic levels (clinical levels' dental students and internship dentists) to the question number 14 in which asking about NaOCl if it serves as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis and to help determine whether to proceed with partial pulpotomy, complete pulpotomy, or pulpectomy. The detailed answers of the survey questions related to VPT are presented in [Table 1].
Table 1: The answers of the questions about vital pulp therapy

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The internship students significantly answered better than clinical level' students to four questions (P < 0.05). These questions are number 5, 7, 10, and 11. While there was no significant statistical difference between the two academic levels (clinical levels' dental students and internship dentists) in term to the answers of most questions. On the other side, when compare the answers between government college students and private college students, we showed no significant statistical difference between the two groups related to most questions. Only six questions were answered significantly better by government college students in comparison with private college students (P < 0.05). These questions are number 4, 6, 7, 8, 11, and 15.


  Discussion Top


VPT is a biologic and conservative treatment modality to preserve the vitality and function of the coronal or remaining radicular pulp tissue in vital permanent teeth.[9] Several studies have been conducted to meet this important aspect. However, the survey-based researches about (VPT) are rare. In 2018, Pishbin et al. designed a survey about (VPT),[13] but the content of this study was totally different from the questionnaires used in this study, so we have not found in literature any study similar to ours to compare with. The selected academic centers (government and private) in this study were considered as a sample of the dental colleges of the Saudi Universities.

High percentage of participants (74.4%) agreed that an open apex is present in the roots of immature teeth until apical closure occurs approximately 3 years after the eruption.[14],[15] It was mentioned that immature teeth may require up to 5 years or more to gain apical closure after emergence into the oral cavity.[16] 71.3% of participants supported the information of Ohman[17] and Andreasen[18] that sensibility tests may be unreliable after traumatic injuries, which consider an important tip before starting any type of VPT. Due to drawbacks of conventional periapical radiographs the need to analyze the area of interest three-dimensionally led to the introduction of CBCT.[19] It has concluded that the use of CBCT technique provides more accurate information about the root formation compared to conventional radiographs.[20] In this study, there was good awareness about the importance of this technique to evaluate the case before VPT selection. About 80% of participants realize that the new technology as CBCT is so much helpful in building an accurate diagnosis prior to VPT. It is well known that in case of irreversible pulpitis or pulpal necrosis, the suitable treatment is depending on the degree of root development. If root development is completely formed and the apex is closed, conventional root canal therapy can be performed. When root development is incomplete, root-end closure by apexification must be induced before root canal obturation. A recent trend of VPT proved that it is possible to perform VPT on mature teeth irreversibly inflamed.[21] As it is understood that there are a lot of scientific opinions depending on clinical treatments; so it is very important to know that the primary objective of VPT is to maintain pulp vitality to initiate reparative process such as tertiary dentin formation.[21] 71.9% of participants were familiar with the definition of apexogenesis which is a VPT procedure performed to encourage continued physiologic development and formation of the root end.[10],[22] While 65% agreed that the objective of apexogenesis is to maintain the vitality of the radicular pulp,[10],[22] only half of the participants knew that apexogenesis allows generating dentine bridge at the site of pulpotomy.[10],[22] 75.2% of respondents showed a knowledge of the indication of indirect pulp capping, as it is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration.[20] 54.5% of participants realize that in indirect pulp capping the patient returns in 8–12 weeks for the placement of a permanent coronal restoration.[20] Ca(OH)2 has long been considered the universal standard for VPT materials. The introduction of Ca(OH)2 into dentistry is credited to Hermann in the 1920s. Desirable characteristics of Ca(OH)2 include an initial high alkaline pH which is responsible for stimulating fibroblasts and enzyme systems. The drawbacks of Ca(OH)2 include weak marginal adaptation to dentin, degradation, and dissolution over time.[20] More than 70% of internship dentists and clinical levels' dental students have background that the unique physiochemical properties of MTA promote a superior environment for pulpal repair and bridge formation compared to Ca(OH)2 products.[23] Of all participants, 64.5% are aware of the statement” If bleeding cannot be controlled after 10 min of direct exposure to NaOCl after removal of unhealthy tissue, complete removal of the coronal pulp to the pulp floor is the preferred option.[20] The low percentage of participants 27.8% realized an important side of NaOCl that it serves as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis and to help determine whether to proceed with a partial pulpotomy, complete pulpotomy, or pulpectomy.[20] The outcomes for VPT can vary depending on the age of the patient, extent of bacterial contamination, and degree of pulp inflammation. Perhaps of greater importance may be the choice of pulp capping material and the quality of the permanent restoration.[24] 26.2% of participants did not know that caries detector dyes can be considered a valuable tool in caries excavation when attempts are made to preserve remineralizable dentin and to minimize trauma to the pulp.[25] Only 39.7% of participants agreed with this proved information if MTA is substituted for Ca (OH)2 in VPT. Procedures, similar time periods for apical maturation can be anticipated.[26],[27]

The results of this survey-based study revealed that there was no significant statistical difference between the two academic levels (clinical levels' dental students and internship dentists) and between government college students and private college students related to the answers of most questions. This may be due to advanced and similar curriculums which granted to the students who registered in the dentistry program in Saudi dental schools.


  Conclusion Top


Within the limitations of this survey-based investigation among internship dentists and clinical levels' dental students, it was concluded that the participants had an average knowledge about the different types and steps of VPT. There is still a knowledge lack in some points requires more focusing, in addition to the need of more lectures about the new materials used in endodontic field which is very quick developed branch of dentistry, and it is very necessary to enhance the knowledge of student about VPT through clinically performance of some cases in term to this aspect.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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