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Attitudes and Behaviour regarding Deep Dentin Caries Removal: A Survey

among German Dentists

Article  in  Caries Research · July 2013

DOI: 10.1159/000351662 · Source: PubMed

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 Original Paper

Caries Res 2013;47:566–573 Received: October 26, 2012

Accepted after revision: April 18, 2013
DOI: 10.1159/000351662
Published online: July 26, 2013

Attitudes and Behaviour regarding Deep

Dentin Caries Removal: A Survey among
German Dentists
F. Schwendicke a H. Meyer-Lueckel b C. Dörfer a S. Paris a
       

a
  Department of Conservative Dentistry and Periodontology, Christian Albrecht University, Kiel, and b Department of  

Operative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University, Aachen, Germany

Key Words rejecting incomplete excavation and vice versa. Cluster

Attitudes · Behaviour · Caries · Dentists · Excavation · analysis identified two groups of dentists with opposite at-
Incomplete · Partial · Questionnaire · Removal · Survey titudes and behaviour, independently from dentist’s age or
gender. In conclusion, the majority of surveyed dentists was
sceptical about leaving caries during excavation and does
Abstract not practice incomplete caries removal. Therefore, benefits
Incomplete removal of deep caries has been shown to re- of partial excavation should be highlighted in under- and
duce the risks of pulp exposure and postoperative pulpal postgraduate education and regulatory incentives modi-
complications. It is therefore of interest whether dentists fied to promote minimally invasive techniques.
perform one- or two-step incomplete excavation, and Copyright © 2013 S. Karger AG, Basel
which criteria and methods they use to assess and provide
removal of deep caries. This study investigated the atti-
tudes and behaviour of dentists in northern Germany using Operative treatment of dental caries was, for most of the
a new, validated questionnaire. The survey included 2,346 last century, based on the removal of all infected biomass
practitioners, 821 (35%) of whom responded. Demographic and replacement of lost dental hard tissue. This concept
and sensitivity analysis did not indicate selection bias. 50% was founded on both an understanding of caries as an in-
of dentists considered only complete excavation, even if fectious disease caused by specific bacteria which require
pulp exposure was likely. If caries was to be removed in- eradication as well as a limited choice of dental materials
completely, 77% considered two-step excavation. Hardness all requiring extensive cavity preparation prior to restora-
was the most important criterion to assess excavation. To tion. The changing understanding of caries as an ecologi-
treat an exposed pulp, 75% of dentists considered direct cal imbalance within the biofilm rather than a specific in-
capping, 70% refused incomplete excavation fearing caries fection [Fejerskov et al., 2008] and the availability of treat-
progression or pulp damage, and 59% reported to prefer ment options such as caries sealing, resin infiltration or
more invasive treatment to facilitate restoration longevity. adhesive restorations challenge this approach. It is now
Over 50% recognised an influence of professional regula- widely accepted that preservation of dental tissue is usu-
tions on their treatment decisions. There was a moderate ally preferred to its removal, and restorative treatment is
correlation between attitudes and behaviour of dentists, regarded as the start of a subsequent cycle of restorations
with dentists who suspected residual caries to be harmful [Brantley et al., 1995], eventually leading to tooth loss,
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Charité - Universitätsmedizin Berlin

© 2013 S. Karger AG, Basel Dr. Falk Schwendicke

0008–6568/13/0476–0566$38.00/0 Department for Conservative Dentistry and Periodontology
Christian Albrecht University Kiel
Downloaded by:

E-Mail karger@karger.com
Arnold-Heller-Strasse 3, DE–24105 Kiel (Germany)
www.karger.com/cre
E-Mail schwendicke @ konspar.uni-kiel.de
hence described as ‘the death spiral of the tooth’ [Qvist, feel about leaving caries under a restoration, and how much
2008]. Whilst numerous non- and microinvasive ap- caries do they remove in deep cavities? (3) Is there a corre-
proaches successfully arrest caries, certain cavities will lation between a dentist’s understanding of caries, its treat-
doubtlessly need to be restored. Based on the described ment and the dentist’s age, gender and/or clinical setting?
understanding of caries, with alteration of the biofilm pre-
sumably being more important than its removal, questions
like ‘how clean must a cavity be?’ [Kidd, 2004] or ‘how Materials and Methods
much caries must be removed?’ [Ricketts, 2008] now arise. Questionnaire Design and Validation
The treatment of deep dentin caries is daily practice for Based on questions of interest, a questionnaire was designed
most dentists worldwide. Nevertheless, there is no con- and tested by experts (Christian Albrecht University, Kiel, and
sensus in the dental profession regarding excavation RWTH Aachen University, Aachen), a focus group of six dentists,
depth, technique, or suitable diagnostic criteria or aids for and within a pilot study involving random dentists (n = 18) in
southern and eastern Germany. Results of the latter were used to
caries removal. Although there are very limited data on assess objectivity and internal consistency of the questionnaire. A
how general practitioners treat deep caries, it can be as- test-retest procedure with a group of undergraduate dental stu-
sumed that complete removal of all affected biomass is dents (n = 20) was used to assess reliability. Content validity was
common [Oen et al., 2007; Weber et al., 2011], as genera- tested by a validation panel at Christian Albrecht University Kiel
tions of dentists have traditionally been taught complete and RWTH Aachen University.
Interrater and test-retest reliability were excellent (Cohen’s
eradication of the ‘carious infection’. However, an in- kappa and Kendall’s tau were 0.98 and 0.79 [p < 0.001 for both],
creasing number of clinical trials [Leksell et al., 1996; Lula respectively). Internal consistency was found to be acceptable
et al., 2009; Bjørndal et al., 2010] showed fewer pulpal (Cronbach’s alpha was 0.72, p = 0.007), with only one battery item
exposures and complications when deep caries was not (no. 8: preference of invasive or less invasive treatment) showing
completely removed, but partially remained under a res- questionable consistency (α = 0.56) [Tavakol and Dennick, 2011].
The questionnaire was finalised accordingly, containing nine bat-
toration, thus being ‘entombed’. These remaining micro- tery items, and was approved by the ethics committee of the Uni-
organisms, it seems, are deprived of nutrition, which versity Hospital Schleswig-Holstein (AZ AD 437/12). Closed re-
leads to alteration of the flora with subsequent caries ar- sponse modes were used, with binary or multiple choice or 4-score
rest and re-hardening of formerly soft dentin [Bjørndal et Likert scale batteries. One question allowed the addition of re-
al., 1997; Maltz et al., 2002]. marks. The complete translated questionnaire and a summary can
be found in the online supplementary material and in table 1, re-
However, one- and two-step incomplete caries remov- spectively (for all online suppl. material, see www.karger.com/
al [Bjørndal et al., 2010; Maltz et al., 2011] or even no car- doi/10.1159/000351662).
ies removal at all [Innes et al., 2009; Gruythuysen, 2010]
are frequently seen as a renunciation of more than a cen- Survey Conductance
tury of restorative dental treatment. Thus, it is of great A mail survey based on the modified tailored design method
was used. The latter aims to achieve high response rates, with re-
interest to know how established these techniques are in spondent-friendly questionnaire design, multiple contact ap-
general dental practice. Anecdotic evidence shows that proaches, sent return envelopes and a personalised correspondent
leaving caries under a restoration is frequently seen as letter [Thorpe et al., 2009]. Collaborating with the state dental reg-
professional neglect, and studies investigating this issue ulatory body (Zahnärztekammer) we sent questionnaires, cover
showed that dental treatment may be less driven by evi- letters and prepaid return envelopes to all registered and clinically
active dentists in Schleswig-Holstein, a northern federal state of
dence than experience, with theory and practice being Germany (n = 2,346, comprehensive survey). The survey had been
somehow incongruent [Brennan and Spencer, 2007; Oen announced two weeks beforehand in the dental board magazine.
et al., 2007; Doméjean-Orliaguet et al., 2009; Riley et al., All responses were anonymous. After two weeks, we sent e-mail
2011; Weber et al., 2011]. It is however not clear why this reminders with a link to download the questionnaire for print mail
knowledge might not have entered general practice, or if or e-mail answer.
there is an increase in less invasive caries excavation tech- Sensitivity Analysis
niques by younger dentists. Since data protection guidelines prohibited self-identification
The present study therefore investigated the knowledge, of responders, we contacted 200 randomised dentists stratified for
attitudes and behaviour of dentists in northern Germany age, gender and practice location. In total, 59 of these dentists were
regarding removal of deep dentin caries based on a ques- willing to identify themselves as ‘previous non-responders’ and
took part in the survey. Response data for this group were analysed
tionnaire survey. The following questions were of interest: separately, and sensitivity analysis of response data of both groups
(1) Are dentists aware of different options to treat deep car- regarding caries diagnosis and treatment (battery items 1–8) was
ies and of their respective success rates? (2) How do dentists performed. After a total of six weeks the survey was closed.
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Table 1. Summarized contents of item batteries within the questionnaire used (the complete questionnaire can be found in the supple-
mentary material)

Item Content
1 criteria to assess sufficient removal of primary caries close to the pulp if pulp exposure is likely
2, 4 excavation methods and cavity treatment before adhesive restoration
3 treatment of choice to remove caries in proximity to the pulp in a vital tooth of a 20-year-old patient
5 expected success rates of direct capping, root canal treatment and incomplete or stepwise excavation
6 attitudes regarding complete and incomplete caries removal and reasons for these attitudes
8 attitudes regarding treatment priorities: restoration longevity versus invasiveness of treatment; influence of legal regulations
7 monitor or re-treat an asymptomatic tooth with a radiolucency under the restoration in proximity to the pulp

Statistical Analysis Of these, 54 and 26% used calcium hydroxide cement and
Questionnaire data were organised using a databank (Excel 10, suspension, respectively, and 20% both. 4% of dentists
Microsoft, Redmond, Wash., USA). Statistical analysis was per-
formed using SPSS 20 (IBM, Armonk, N.Y., USA). Data were con-
stated that they used other lining materials, 36% com-
trolled for normal distribution using Shapiro-Wilk test and descrip- bined calcium hydroxide with another liner.
tive analysis performed accordingly. Statistical comparison of the If faced with a 20-year-old patient with deep dentin
groups was performed using Mann-Whitney U test (continuous caries with risk of pulp exposure and several possible
data: date of birth and years since dental licence) or χ2 test (nominal treatment options, 50% of 799 dentists who answered that
and ordinal data: all other items). Correlation analysis was per-
formed using Kendall’s tau. If values were missing, the sample was
question only considered complete excavation, even if
excluded from analysis. Statistical significance was set at p < 0.05. pulp exposure was likely. 20% only found incomplete ex-
To assess patterns of answers between items, data were firstly cavation an option to avoid exposing the pulp. The re-
transformed into binary variables. Afterwards, univariate analysis maining 30% considered both. If pulp exposure occurred,
using χ2 test was performed to select variables for inclusion within 75% of dentists would perform direct capping. Two-step
dimensional analysis. Multivariate analysis by multidimensional
scaling was used to analyse data structure and proximities. Goodness
excavation was the preferable choice for 77% of dentists
of fit of the model was assessed using Kruskal’s stress test. Based on who considered incomplete caries removal, whilst only
calculated dimensions, clusters (items with proximity) of diagnostic 23% of dentists would provide one-step incomplete exca-
or treatment patterns and dentists’ characteristics were identified. vation.
Dentists were asked to assign expected 2-year success
rates to certain treatments associated with caries removal
Results in proximity of the pulp in a 20-year-old patient (table 3).
If analysed for possible correlation, dentists who expected
The response rate was 35%; 821 of 2,346 contacted den- direct capping to have high success rates chose this meth-
tists answered. Demographic data did not show any statis- od more frequently, whilst dentists performing one-step
tically significant difference between responders and all incomplete removal assumed this method to be more suc-
registered dentists (p > 0.05, χ2 test/Mann-Whitney U test), cessful (tau = 0.29 and 0.32, respectively).
and sensitivity analysis of previous non-responders did not Further analysis investigated dentists’ attitudes re-
indicate selection bias (online suppl. tables 1 and 2). garding caries and its removal. 72 and 73% of dentists
The vast majority of dentists stated that they used two agreed or strongly agreed that complete caries removal is
or more criteria to assess caries removal close to the pulp, necessary to avoid caries progression and pulpal compli-
with hardness being the most frequently used criterion. cations, respectively, and refused to leave caries under a
Only few dentists used chemo-mechanical excavation or restoration or perform incomplete excavation. If asked
polymeric burs to excavate caries (table 2). To adhesively for their preferred treatment strategy, 59% of dentists
restore deep cavities, only 11% of dentists reported not agreed or strongly agreed to follow a more invasive ap-
using any liner, but placing the bonding directly onto the proach to achieve high restoration longevity, whereas
dentin. 49% declared using a form of calcium hydroxide. 46% accepted re-treatment as a possible result of a less
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Table 2. Chosen criteria to assess and methods to perform excavation of deep dentin caries (n = number of responders)

‘Which criteria do you use to assess sufficient removal of primary caries close to the pulp?’
Hardness (n = 760) 1% soft 21% leathery 76% hard 2% not relevant
Colour (n = 760) 18% very discoloured 34% slightly discoloured 5% not discoloured 43% not relevant
Moisture (n = 758) 0% wet 12% slightly moist 76% dry 12% not relevant
Further criteria (n = 803) 5% dye staining 1% shiny reflection <1% diagnodent <1% others
Excavation (n = 760) 97% metal bur 25% ceramic bur 58% hand excavator 4% chemical excavation
4% polymeric bur

Table 3. Percentage of dentists who assumed respective 2-year survival rates (survival = no re-treatment necessary) of several treatment
options for deep dentin caries (n = number of responders)

0–20% 21–40% 41–60% 61–80% 81–100% Not specified

Direct capping (n = 799) 11% 22% 33% 26% 6% 2%

Root canal treatment (n = 799) 1% 1% 7% 33% 54% 4%
Indirect capping (n = 800) 1% 4% 10% 35% 48% 2%
Incomplete excavation (n = 800) 26% 21% 21% 15% 6% 11%

Table 4. Attitudes of dentists towards leaving caries under a restoration and restorative treatment strategies (n = number of responders)

Strongly Disagree Agree Strongly Not

disagree agree specified

Leaving caries under restorations (n = 800)

‘Cariogenic microorganisms need to be removed completely, since
caries might progress otherwise’ 12% 14% 20% 52% 2%
‘Certain amounts of cariogenic microorganisms can be left, since intact
restorations can seal and thus arrest caries’ 34% 22% 23% 17% 4%
‘Caries should always be removed completely, since residual caries is a
risk for the vitality of the pulp’ 9% 15% 20% 53% 3%
‘Caries in proximity to the pulp should be left to avoid pulp exposure’ 47% 23% 18% 8% 4%
Restorative strategy/treatment priority (n = 801)
‘I prefer invasive methods if this enhances restoration survival’ 12% 25% 29% 30% 4%
‘I prefer less invasive methods and accept possible re-treatment
(repair etc.)’ 22% 28% 25% 21% 4%
‘Regulations enforce rather invasive methods to avoid re-treatment
within guarantee time’ 21% 13% 23% 31% 13%

invasive therapy. 54% recognised that certain legal regu- ies. They were informed that the tooth was vital, asymp-
lations (guarantee times etc.) influenced their treatment tomatic and the filling placed six months ago. Only 14%
decisions (table 4). of the dentists agreed to re-treat the tooth, whilst 86%
Eventually dentists were asked to assess a radiograph decided to monitor it.
(online suppl. fig. 1) showing a restored molar with a deep Age, gender and practice setting of dentists were not
composite restoration and pulpo-proximal residual car- found to be significantly associated with any clinically rel-
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 0.50

Renew filling

0.25 1-visit incomplete

Leave caries (sealed)

Hard cavity floor
Direct capping
Complete excavation (progression) Less invasive (re-treatment)

Dimension 2
0
Complete excavation (pulp) Leave caries (avoid exposure)
Invasive for longevity
Monitor filling
Fig. 1. Multidimensional scaling analysis of Root canal Stepwise excavation
treatment patterns and attitudes regarding
caries removal. Two clusters of opposite at- –0.25 Leathery cavity floor
titudes and behaviour towards caries re-
moval emerged (grey ellipses). Grey boxes
and black circles indicate answers concern-
ing caries and treatment ‘philosophy’ or
chosen treatment of the described clinical
case. Black rings code used excavation cri-
–0.50
teria. The decision to either re-treat or –0.50 –0.25 0 0.25 0.50
monitor the restoration based on radio- Dimension 1
graphic diagnosis is not fitting within clus-
ters.

evant variable (tau –0.2 to +0.2). To identify possible pat- direct and indirect capping or root canal treatment,
terns within obtained data, we performed a multivariate which were moderately associated with chosen treat-
analysis of ‘caries-related’ variables using multidimen- ment. Despite limited expectations regarding its success,
sional scaling (fig. 1). Two opposite clusters determined many dentists considered performing direct capping. (2)
by the chosen caries removal criteria, preferred treatment Over 70% of dentists refused to leave caries under a res-
for deep caries and general ‘caries philosophy’ were iden- toration. This decision is influenced by the idea that re-
tified. Correlation analysis confirmed the proximity of sidual caries might progress or harm the pulp. (3) We
variables within each cluster, and dentists who rejected found no significant association between age, gender
the idea of leaving caries were more likely to consider only and/or practice setting and dentists’ understanding and
complete excavation, whilst dentists who agreed that treatment of caries. In contrast, cluster analysis identified
sealed caries would be arrested considered incomplete re- two opposite types of dentists characterised by their at-
moval more often (tau > 0.3). titudes and behaviour, with each cluster showing a logical
coherence. Dentists who aimed at high restoration lon-
gevity more frequently refused to leave caries under a
Discussion restoration, and excavated further than dentists who pre-
ferred less invasive methods.
Within this study n = 821 dentists from northern A major problem when investigating caries removal is
Germany were surveyed regarding their diagnostic and the lack of well-defined excavation criteria (‘soft’, ‘leath-
therapeutic methods, attitudes and behaviour regarding ery’, ‘heavily discoloured’), mainly due to a lack of objec-
deep dentin caries excavation. Several points need to be tive, reproducible and accurate methods to measure the
highlighted: (1) Dentists were aware of success rates for amount of removed or remaining caries. These subjective
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criteria, however, have been proven useful in dental prac- caries removal. Our findings indicate that these differ-
tice and research, and were found to correlate with mi- ences may not be closely related to certain characteristics
crobial findings after excavation [Kidd et al., 1996]. Using of the dentists, but are rather influenced by a greater
such subjective descriptions in a survey like the present ‘theme’ a dentist follows during diagnosis and therapy,
one can, however, cause a certain degree of interpretation with coherence of knowledge, attitudes and treatment de-
bias, and various used terms (e.g. indirect capping) may cisions regarding deep caries removal.
be understood differently by different dentists. Dentists in northern Germany frequently chose to per-
To limit such bias and improve the validity of the study, form direct pulp capping. The popularity of this treatment
the questionnaire was controlled for objectivity, reliabili- option was shown in other countries, too [Oen et al., 2007;
ty  and validity before commencing the survey. The Bergoli et al., 2010]. At first glance, this is in contrast with
achieved response rate was similar to other international relatively poor prognosis of direct pulp caps, with report-
and German surveys [Naumann et al., 2006; Müller et al., ed success rates of 32 or 37% after one or five years [Bar-
2008; Greenberg et al., 2010; Hertrampf et al., 2012], and thel et al., 2000; Bjørndal et al., 2010]. Interestingly, den-
confirms a trend of decreasing participation willingness of tists in our survey were mostly aware of such limited suc-
dentists [Schiffner et al., 2009]. However, demographic cess rates (the median expected 2-year success rate was
analysis indicated a nearly perfect congruence between re- 41–60%). Thus, it seems, direct capping was performed
sponders and all registered dentists, and there was no sta- more due to lack of alternatives than due to conviction,
tistical difference in attitudes and behaviour of responders since most dentists attempted to perform complete exca-
and previous non-responders. However, previous non-re- vation, but avoided root canal treatment. The irreversible
sponders included only dentists who voluntarily respond- and invasive character of root canal therapy may prevent
ed after being directly contacted; the performed sensitivity dentists from choosing endodontic treatment as a first
analysis is therefore of limited value. In conclusion, it is step. Direct capping is likely seen as less radical, and after
impossible to guarantee representativeness of sampled possible failure of capped teeth, endodontics can still be
dentists, but based on described analyses selection bias performed with a presumably similar prognosis.
seems unlikely. In general, interpretation of survey data Alternatives like one- or two-step incomplete caries
should be performed with caution, since surveyed theory removal were not considered by the majority of respond-
and clinical practice will likely differ to a certain degree. ing dentists, concurring with studies from the United
This can be due to the complexity of influence factors on States and Brazil, reporting that only 21% [Oen et al.,
clinical decisions, which is difficult to simulate in a ques- 2007] and 26% [Weber et al., 2011] of dentists considered
tionnaire, and the fact that mail-based surveys yield only incomplete excavation of pulp-proximal caries. The re-
self-reported information [Carlsson et al., 2006]. Never- luctance to perform one-step incomplete removal con-
theless, the present study type gained information regard- curred with the relatively low expected success rates of
ing both preferred treatment and reasons for such prefer- this treatment: 47% of the dentists in this study assumed
ence, with data being sampled from a high number of den- that such therapy had a 2-year success rate of <40%. These
tists. This would not have been possible with alternative low expectations are in contrast with current scientific
methods (claim data analysis, focus group observations). evidence. A clinical long-term study investigating one-
The present study did not find any significant associa- step incomplete removal of deep dentin caries found a
tion between age, gender and/or practice setting on the 2-year survival rate of 90% [Maltz et al., 2011]. A recent
one hand and the attitudes (e.g. leaving caries under a review and meta-analysis of randomised controlled trials
restoration) and behaviour (excavation methods or crite- comparing incomplete and complete excavation [Schwen-
ria) regarding caries removal on the other hand. These dicke et al., 2013] confirmed significantly reduced risks of
findings are in contrast with several other studies, which pulp exposure (odds ratio [OR]  = 0.31 and 95% confi-
showed correlations between restorative behaviour and dence interval [95% CI] = 0.19–0.49) and pulpal compli-
age [Bader and Shugars, 1992; Mejàre et al., 1999; Do- cations (OR = 0.58, 95% CI = 0.31–1.10) for incomplete-
méjean-Orliaguet et al., 2009], gender [Riley et al., 2011], ly compared to completely excavated teeth. Risk of failure
practice size [Gordan et al., 2012] or dental education and did not seem to be significantly increased (OR = 0.97, 95%
experience of the dentist [Bader and Shugars, 1997; Riley CI = 0.64–1.46). Therefore, the fear of putting the pulp at
et al., 2011; Weber et al., 2011; Gordan et al., 2012]. The risk when leaving deep caries in proximity to the pulp
present study did however identify two groups of dentists lacks scientific evidence, and there is currently no indica-
with opposite attitudes and behaviour regarding deep tion that successfully sealed residual caries lesions are at
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considerable risk to progress [Bjørndal et al., 1997; Maltz deep caries. None of the discussed variables was consider-
et al., 2002]. However, the follow-up periods of most ably associated with the dentist’s characteristics. It is
studies investigating incomplete excavation are rather therefore possible that other factors such as contempo-
short; conclusions regarding long-term survival of in- rary under- and constant postgraduate education, per-
completely excavated teeth are thus limited. sonal experience, an established practice concept or the
It is therefore understandable that dentists are scepti- individual approach to restorative dentistry may be more
cal towards the long-term success of such treatment. Pos- important than the dentist’s age or practice setting. It
sibly inferior longevity of restorations after incomplete would, however, be of great interest to re-evaluate our
caries removal was stated as one reason not to choose this findings in the future and to assess whether a possible
treatment option. The lack of consensus on how much change in dental education had an impact.
caries needs to be removed and ambiguity about how the Within the limitations of the present study it can be
degree of excavation correlates with treatment outcomes concluded that the majority of dentists in northern
may discourage dentists further. In contrast, dentists Germany attempt complete removal of deep dentin car-
might feel that complete caries removal can achieve both ies, since they fear residual caries may progress or harm
removing the ‘right’ amount of caries and reducing the the pulp. These findings are not related with age, gender
risk of restoration failure. The latter is especially impor- or professional setting. In contrast, attitudes and behav-
tant for German dentists since there are certain regula- iour regarding caries removal seem to correlate with each
tions, for example a two-year guarantee time, which en- other, which was reflected in the identification of two
force restoration longevity rather than minimally inva- groups of dentists with opposite approaches to caries ex-
sive treatment options. Therefore, more clinical long-term cavation. The benefits of less invasive caries removal tech-
studies are needed to convincingly investigate survival of niques should be highlighted in under- and postgraduate
incompletely excavated teeth. In addition, governmental dental education, and professional regulation should em-
bodies or insurances are invited to promote minimally brace minimally invasive caries treatment. Long-term
invasive approaches and alter reimbursement and regula- clinical studies are required to convincingly assess the
tory incentives accordingly. performance of incompletely excavated teeth.
Lastly, it needs to be highlighted that dentists follow a
complex treatment pattern or ‘script’, with a great num-
ber of influence factors [Bader and Shugars, 1997]. This Acknowledgements
was demonstrated when facing practitioners with a radio-
The authors want to thank the Zahnärztekammer Schleswig-
graph showing a deep restoration with residual caries in
Holstein for their support and cooperation and all participating
direct proximity to the pulp. Only 14% of dentists decid- dentists for their contributions. Furthermore, the work of Erik
ed to intervene. There are several possible reasons for this Fleischer in evaluating questionnaires and organising the non-re-
finding. Firstly, the depicted ‘visual’ risk of exposing the sponder analysis is greatly appreciated. We are grateful to Dipl.-
pulp and the possible conflict with a patient who does not Inf. Jürgen Hedderich, Institute for Medical Informatics and Sta-
tistics, Christian Albrecht University, Kiel, for his statistical sup-
report any need for treatment could have put dentists off.
port and advice. Many thanks to Dharshani Anandanesan-Midgley
Secondly, re-treatment of this tooth would have likely re- (BDS, PGDp [Bris]) for proof-reading the manuscript.
quired the provision of a crown, with associated loss of
hard tissue and additional costs. Thirdly, dentists may
have been reluctant to re-treat a tooth only six months Disclosure Statement
after the original therapy. A detailed and reliable evalua-
tion of the factors affecting such clinical decisions is how- The authors declare no interest conflict. The study was funded
ever not possible within a survey. by the authors and their institutions.
The present study identified two ‘types’ of dentists
based on their attitudes and behaviour regarding deep
caries removal. The attitudes regarding the disease (e.g. Author Contributions
leaving caries under a restoration), the expectations re-
garding certain treatment options as well as a dentist’s Development of the protocol and the questionnaire: F. Schwen-
dicke, S. Paris. Validation and pilot study: F. Schwendicke. Survey
general therapy strategies and priorities (e.g. restoration organisation, analysis and interpretation of data: F. Schwendicke,
longevity) seem to correlate with each other, leading to a S. Paris. Manuscript preparation: F. Schwendicke, S. Paris, H. Mey-
somewhat coherent concept of diagnosing and treating er-Lückel, C. Dörfer.
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572 Caries Res 2013;47:566–573 Schwendicke/Meyer-Lueckel/Dörfer/Paris

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