Endodontic Treatments in Primary Teeth among Brazilian Dental Practitioners: A Preliminary Nationwide Cross-Sectional E-SurveyABSTRACT
Objective: To preliminarily evaluate the endodontic treatments in primary teeth carried out by Brazilian dental practitioners.
Materials and Methods: A preliminary nationwide cross-sectional e-survey was conducted. The data collection took place from December 2023 to January 2024. The sample consisted of 77 dental practitioners, based on their initial responses to a 32-item self-administered questionnaire that addressed the features of treatments provided in Portuguese. The instrument was made available online, and its link was distributed via messaging apps and social media campaigns. The significance level was set at 5% (α = 0.05), and Pearson's chi-squared test was used to assess associations.
Results: Among the respondents, 61% carry out indirect pulp capping, 53.2% carry out direct pulp capping, 40.3% carry out pulpotomy, and 31.2% carry out pulpectomy in primary teeth. Respondents aged up to 35, working in public dental services, and self-assessing their knowledge as 'very good' or 'good' were more likely to provide some endodontic treatment in primary teeth (all p <0.05). Furthermore, 41.6% of the respondents did not rate their knowledge about endodontic treatments in primary teeth as 'very good' or 'good', and 49% of the providers reported referring children in need of endodontic treatments 'frequently' or 'occasionally'. Calcium hydroxide was the most commonly used material for direct or indirect pulp capping (78.7% and 68.1%, respectively) and pulpectomies (54.2%). In pulpotomies, Mineral Trioxide Aggregate (MTA) was the most frequently used material (45.2%), with its usage similar to that of calcium hydroxide (38.7%).
Conclusion: There was notable variability in the characteristics of endodontic treatment providers for primary teeth among Brazilian dental practitioners.
Keywords:
Pediatric Dentistry; Endodontics; Tooth; Deciduous; Surveys and Questionnaires.
Introduction
Endodontic treatments, whether conservative or radical, are essential in dental offices. Primary and permanent teeth, with vital or non-vital pulp status, often require these therapies to address dental caries or trauma. In both modalities, the advancement of Endodontics as a field of knowledge is noticeable, directly influencing clinical practice, considering evidence-based approaches [1,2]. However, there is a concern within the scientific community about the factors affecting the provision of endodontic treatments, ranging from dental education to characteristics associated with dental practitioners and services [3,4].
In fact, providing endodontic treatments can be a challenging task that requires proper training to consolidate theoretical and practical knowledge and apply it in various clinical settings. In addition, a wide range of techniques, technologies, and dental materials can be utilized in multiple endodontic therapies, resulting in heterogeneous clinical practices among dental practitioners [3,4]. Considering endodontic therapies for children, dental practitioners also need to develop skills related to pediatric dental care, taking into account the particularities inherent to this age group, such as behavior management techniques in dental offices and the unique aspects of Endodontics in primary teeth [5,6].
However, as far as was possible to verify, in comparison to permanent teeth, there is a scarcity of studies properly describing and analyzing endodontic treatments in primary teeth provided by dental practitioners, highlighting a gap in the state of the art. It is essential to acknowledge that researching this gap presents numerous challenges, particularly in obtaining representative samples across vast territories. Brazil, for instance, is a country of continental dimensions, with five distinct regions [7] and a high number of dental practitioners and services (409,406 and 76,871, respectively, as of March 2024) [8]. In addition, this country has a robust public healthcare system that provides dental care to Brazilians, in contrast to the private sector [7].
This context highlights the importance of evaluating endodontic treatments in primary teeth among Brazilian dental practitioners. Electronic surveys (e-surveys) can help address this research topic, and previous approaches have shown good adherence from this population to this method [9,10]. However, considering that it is a nationwide approach, a pilot study has become feasible to check methodological aspects and obtain a more reliable parameter for sample size and data collection strategies, in addition to providing preliminary insights on this topic [11]. Therefore, the objective of this study was to preliminarily evaluate the endodontic treatments in primary teeth performed by Brazilian dental practitioners, using a pilot study design.
Material and Methods
Study Design
This was a pilot study, considering a preliminary observational, cross-sectional, and quantitative design [12], and conducted in an online environment (e-survey). Then, electronic tools available on the internet were employed to invite and collect data from participants. Moreover, considering the rigor of scientific communication, all items outlined in the Preferred Reporting Items for Observational Studies in Endodontics (PROBE) checklist, version 2023 [13], were used to structure this report.
Ethical Clearance
The study protocol, encompassing all stages, was submitted for approval to the Research Ethics Committee at the institution where it was conducted (School of Dentistry of Ribeirão Preto, University of São Paulo) and received approval (Opinion nº 6.138.147). The development of this study was based on the current legislation regarding human involvement in Brazil, including the recommendations of the National Commission on Research Ethics for data collection in online environments in this country. All participants electronically marked their agreement (Informed Consent Form - ICF) upon receiving proper information about the study. Participation remained anonymous, with only the collection of participants' name initials to enable withdrawal from the study if desired. An e-mail address was provided for inquiries or withdrawals, and the ICF was available for download.
Population, Sample, and Sampling
The study population comprised Brazilian dental practitioners enrolled in Brazil's Federal Council of Dentistry, aged 18 years or older, and actively engaged in clinical practice. There were no restrictions related to the type of clinical practice or dental specialty. The sample size for the pilot study was determined as 20% of the number obtained if the maximum variability of the primary outcome (50%) were used, as it was not possible to achieve a better parameter in contemporary evidence. Considering a margin of error (e) of 5%, a confidence level of 95% (α = 0.05 and Z-score = 1.96), and a finite population of dental practitioners in this country (382,597 - January 2023) [11,14], approximately 77 participants (n = 77) were needed in this preliminary survey. Furthermore, considering the online environment, the sampling was non-probabilistic, including the first 77 Brazilian dental practitioners who agreed to participate.
Outcomes
The primary outcome was the frequency (%) of Brazilian dental practitioners who provide some endodontic treatment in primary teeth (either conservative or radical). Gender, age, region, and sector of clinical practice, as well as specialized education in Pediatric Dentistry (specialist or not), years of experience, and continuing education on endodontic treatments in primary teeth, were collected to characterize the participants. In addition, the participants also self-assessed their knowledge of endodontic treatments in primary teeth and their confidence in indicating and implementing these approaches, both on a 5-point Likert scale. The main features of conservative and radical endodontic treatments were also collected, considering the most commonly used materials (pulp capping, pulpotomy, and pulpectomy), parameters and techniques (working length, instrumentation, obturation levels, irrigant solutions, and intracanal medications), as well as the provision of restorations after these clinical procedures.
Data Collection
The data collection took place from December 2023 to January 2024, using a 32-item self-administered online instrument developed in the Portuguese language (Google Forms, Google Inc., Mountain View, CA, USA). Before the data collection, the questionnaire underwent a face and content validity procedure, demonstrating acceptable appearance, comprehension, and relevance [15]. The link to access the data collection instrument and participate in the study was distributed through messaging apps and Instagram campaigns targeting users/profiles of Brazilian dental practitioners, similar to previous studies [9,10].
For this purpose, an Instagram professional profile was created to promote the study, with a link available. In addition, Instagram posts were added to this profile and used to reach Brazilian dental practitioners (daily reposted on the 'stories' tool), as well as sent via direct messages. Requests to promote the study among peers were also conducted, targeting users/profiles from different Brazilian locations. Upon initial contact with the data collection instrument, all participants were introduced to the study and the ICF, which required them to electronically mark (via checkboxes) for access to the questionnaire.
Data Analysis
After reaching the preliminary sample, the questionnaire was suspended, and the collected data were exported into a spreadsheet for subsequent analysis using the JAMOVI statistical package (version 2.4.11, Sydney, Australia). The significance level was set at 5% (α = 0.05), in which all p <0.05 were considered as a statistically significant outcome. First, a descriptive analysis of the responses provided by the questionnaire respondents was conducted, considering both absolute frequency (f) and relative frequency (fr). According to these frequencies, the main characteristics of the questionnaire respondents were properly dichotomized and associated with the primary outcome (providing some endodontic treatment in primary teeth, either conservative or radical approaches - 'yes' or 'no'/‘providers' or 'non-providers') using Pearson's χ2 test. Whenever p < 0.05, Cramér's V was used to measure the strength of association (magnitude), and the odds ratio (OR) was estimated [16].
Results
Table 1 shows the main characteristics of the questionnaire respondents. The majority of the respondents enrolled in the questionnaire were women, aged 26-35, working in the Southeast region and practicing in the private sector. In addition, most of them were not specialists in Pediatric Dentistry, had ten or more years of experience (clinical practice), and had never undergone continuing education actions on endodontic treatments in primary teeth.
As shown in Figure 1, 30 (39%) do not carry out endodontic treatments in primary teeth (non-providers). Among the providers (47 questionnaire respondents in this preliminary sample, 61%), 47 (61%) performed indirect pulp capping, 41 (53.2%) performed direct pulp capping, 31 (40.3%) performed pulpotomies, and 24 (31.2%) performed pulpectomies.
Table 2 shows the self-assessment of provision and knowledge about endodontic treatments in primary teeth. The majority of questionnaire respondents rated their own knowledge as 'very good' or 'good'. Also, they rated the availability of dental materials in their healthcare services as 'very good' or 'good'. Regarding confidence in indicating and carrying out endodontic treatments in primary teeth, among those who provide at least one type of endodontic treatment, the majority rated themselves as 'very confident' or 'confident' for all approaches evaluated (pulp capping, pulpotomies, and pulpectomies). However, the majority refer children in need of endodontic treatments (regardless of the approach), citing 'special needs' and 'uncooperative behavior' as the more frequent reasons.
Table 3 presents all associations following the dichotomization of variables, examining the provision of endodontic treatments in primary teeth (providers versus non-providers). In this analysis, it was observed that the questionnaire respondents aged up to 35 (versus 36 or older), working in public dental services (versus exclusively in private dental services), and self-assessing their knowledge as 'very good' or 'good' (versus other rates) were more likely to provide some endodontic treatment in primary teeth. Furthermore, respondents who reported years of clinical experience equal to or greater than five years (versus less than five years) and those who reported engaging in some continuing education on endodontic treatments in primary teeth for more than five years (versus less than five years) were less likely to provide some endodontic treatment in primary teeth.
Table 4 presents the main features of conservative endodontic treatments (pulp capping and pulpotomies) in primary teeth, as reported by the respondents to the questionnaire. It was observed that calcium hydroxide was the most widely used dental material among the respondents to the questionnaire, whether for pulp capping or pulpectomies. In pulpotomies, however, Mineral Trioxide Aggregate (MTA) was the most common, although with a relatively close frequency to calcium hydroxide. Furthermore, after indirect pulp capping, the majority of the questionnaire respondents reported providing definitive restorations and follow-up. In contrast, after direct pulp capping, most reported providing provisional restorations and a follow-up interval before providing definitive restorations. Regarding pulpectomies, the majority of questionnaire respondents reported providing definitive restorations and a follow-up interval. However, the relative frequency was similar to that of those who reported providing provisional restorations and a follow-up interval before a definitive restoration.
Table 5 presents the primary features of radical endodontic treatments (pulpectomies) in primary teeth performed by the questionnaire respondents. It was observed that the majority of the questionnaire respondents used the radiographic method to establish the working length, determining the obturation level in relation to the apex at 2mm short for vital pulps and 1mm short for non-vital (necrotic) pulps. Additionally, in both vital and non-vital pulps, 1% sodium hypochlorite was the most commonly used irrigation solution. Moreover, the manual instrumentation technique was the most frequent, and calcium hydroxide was the most widely used filling material during pulpectomies, either associated with zinc oxide or iodoform. Addressing intracanal medications, calcium hydroxide was also the most commonly used in both vital and non-vital pulps. Ultimately, the majority of questionnaire respondents reported providing definitive restorations with a follow-up interval after pulpectomy in primary teeth.
Discussion
This pilot study evaluated the endodontic treatments in primary teeth carried out by Brazilian dental practitioners. Initially, it was observed that the majority of questionnaire respondents had received some endodontic treatment in their primary teeth. Age, years of experience, sector of clinical practice, continuing education, and self-assessment of knowledge were associated with the provision of these approaches. Self-assessment of knowledge and confidence in indicating and carrying out endodontic treatments in primary teeth also showed noticeable frequencies of unsatisfactory responses (different from 'very good' or 'good'). In addition, even among the providers, children in need of endodontic treatments for primary teeth are often referred to other dental professionals/services, especially in cases of uncooperative behaviors or special needs. Most clinical features exhibited specific patterns among Brazilian dental practitioners, and the choice of provisional or definitive restorations varied according to the type of endodontic treatment performed.
These observations cannot be extrapolated or widely applied, as they originate from a preliminary study with a small and restricted sample. Nonetheless, it is essential to note that the study's methodological approach was satisfactory and could be replicated on a large scale to achieve a numerically representative sample of the country in a future study. In a short timeframe, the preliminary sample was reached, no questions regarding the data collection instrument were sent to the researchers, and no withdrawals from the study were requested. In addition, despite the 'prefer not to answer' option, the first 77 respondents contributed to all items of the questionnaire, which could be reflective of ethical actions to safeguard their identity or the appropriate approach to handling sensitive issues related to professional dental practice.
However, upon closer examination, several key points were identified and should be considered for new approaches. Addressing the main characteristics of the questionnaire respondents, women and respondents aged 35 years or younger were the majority. Additionally, the majority were employed in the private sector. These outcomes are similar to those found in a previous study involving Brazilian dental practitioners. They may be related to the profile of users of social networks and messaging apps reached by the data collection strategy employed [8]. Another important outcome was the regional distribution of the questionnaire respondents. According to the Federal Council of Dentistry of Brazil, as of March 2024, approximately 50.8% of Brazilian dental practitioners were practicing in the Southeast region, 18.3% in the Northeast, 15.6% in the South, 9.2% in the Central-West, and 6% in the North [8]. This national parameter was partially reflected in the sample, which can be seen as a positive aspect of the reach of the Instagram campaign and messages (despite a lower frequency in the Southeast region and a higher frequency in the Northeast region compared to what was expected based on the density of Brazilian dental practitioners in each area).
The high frequency of Pediatric Dentists in the sample was also an important outcome. The first hypothesis is that this group may have been more easily reached, as the researchers belong to it, and peer sharing may have favored participation. In parallel, a greater interest in the study's theme also contributed, to a greater or lesser extent, to such frequency. It is noteworthy that Pediatric Dentists represent approximately 7% of the specialized dental practitioners enrolled in Brazil's Federal Council of Dentistry, which also corresponds to approximately 2.3% of all Brazilian dental practitioners in March 2024 [17]. Moreover, another study with this audience demonstrated their good adherence to e-surveys in Brazil, providing a significant number of responses [9,18].
Although specialization in Pediatric Dentistry did not show an association with the provision of endodontic treatments in primary teeth in this sample, the presence of this group inevitably influenced the frequencies of Brazilian dental practitioners who provide, which may have overestimated the overall frequency. This perspective supports the need to adopt data collection strategies that can encompass the audience while introducing the least possible selection bias, aiming for qualitative representativeness beyond the appropriate sample size (numbers). It is also important to highlight that the improvement of e-surveys has enabled analyses that would be challenging through traditional research approaches. Still, there are inherent limitations to the method that often can only be mitigated [19].
Addressing the responses, it is worth highlighting that 41.6% of the respondents did not rate their knowledge about endodontic treatments in primary teeth as 'very good' or 'good'. In addition, among the providers, this frequency ranged from 16.7% (pulpectomy) to 32.2% (pulpotomy). Concomitantly, among the providers, 49% reported referring children in need of endodontic treatments 'frequently' or 'occasionally'. These outcomes raise hypotheses about the difficulties faced by Brazilian dental practitioners in providing endodontic treatments in primary teeth. They should be added to the outcomes, indicating a higher likelihood of providing such treatments among those who undergo some continuing education action in the last five years, among those who have practiced dentistry for less than five years, and who self-assess their knowledge on this topic as 'very good' or 'good'. Indeed, in Brazil's public dental services, endodontic treatments in pediatric patients are often carried out by specialists in Pediatric Dentistry [20, 21].
Indeed, other evidence has already demonstrated the impact of work experience and continuing education actions in Endodontics on the provision of assertive endodontic treatments aligned with the best evidence, including good practices (e.g., use of rubber dam) and the use of new technologies (e.g., rotary instrumentation system) [6,22,23]. Moreover, it is not news that uncooperative behavior in the dental office and special needs are often cited as reasons for not carrying out dental treatments in children, which brings back the need to review how the management of dental behavior and the treatment of patients with disabilities, comorbidities, and other characteristics that require special care are taught in Brazilian dental schools, since there is solid knowledge on both topics [24].
At last, although the features of endodontic treatments in primary teeth require a more in-depth analysis to reach a definitive approach (with an appropriate sample size), thus avoiding misconceptions, some preliminary outcomes deserve attention here. A 2010 study demonstrated that 68.7% of Brazilian dental schools taught direct pulp capping, 98.7% taught pulpotomies, and all taught pulpectomies in primary teeth [25]. Nevertheless, this preliminary study verified that a minority of the questionnaire respondents perform pulpectomies, while the majority of providers reported performing direct pulp capping. Moreover, the use of hand instrumentation technique and 1% sodium hypochlorite as an irrigant solution in vital and non-vital pulp therapies was also observed in another study published in 2019, which involved undergraduate and graduate students in Brazilian dental schools [24], in accordance with this sample.
Ultimately, calcium hydroxide (in powder, paste, or cement form) stands out as the most commonly used material by the questionnaire respondents for pulp capping (both indirect and direct) and pulpectomies, as well as the second most widely used material for pulpotomies (behind MTA) in primary teeth. In 2010, among the Brazilian dental schools enrolled in this study, calcium hydroxide was indicated as the dental material for indirect (59.3%) and direct pulp capping in the majority (97%) [25]. However, this material was not the first choice for pulpotomies (zinc oxide and eugenol, ZOE, 54.2%) and pulpectomies (iodoform paste, 55%). In 2019, among Brazilian undergraduate and graduate participants, the 'Others' option was the most common (42.3% and 40%, respectively). Considering the available responses, Guedes-Pinto paste was more recommended by undergraduate participants in dental schools (30.6%), while calcium hydroxide paste thickened with zinc oxide was more recommended by graduate participants in dental schools (36%) [26,27]. Currently, it is recognized that calcium hydroxide-based materials continue to be investigated in endodontic treatments of primary teeth, either alone or in combination with other materials, yielding overall satisfactory success rates in various clinical settings [1].
Conclusion
A broad overview of Brazilian dental practitioners was obtained in this study, encompassing their sociodemographic, academic, and professional characteristics. Additionally, variations were observed in clinical practice, including techniques, technologies, and dental materials used for this purpose. Furthermore, this pilot study demonstrated that an e-survey can be a viable method for describing endodontic treatments in primary teeth performed by Brazilian dental practitioners. Therefore, the findings from this study should be used to design and conduct a new study with an appropriate sample size and to employ more robust statistical methods to confirm the initial inferences regarding the provision of endodontic treatments in primary teeth by Brazilian dental practitioners.
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Financial Support
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alessandro Leite Cavalcanti
