Abstract
Dental caries is one of the most prevalent chronic diseases globally and within New Zealand (NZ). Deep caries approaches the pulp, is often associated with pain and can lead to pulp exposure. Anecdotal evidence suggests that there is little consistency amongst NZ dentists in the management of deep caries, resulting in different treatments for the same clinical presentation, leading to over- and under-treatment. Although there are international position statements (American Association of Endodontists, AAE and European Society of Endodontology, ESE) for the management of deep caries and vital pulp treatment (VPT), there seems to be limited knowledge and translation of these resources to NZ practice. Implementing guidelines that are evidence-based and offer more biologically conservative and financially viable treatment options for deep caries presents an opportunity to reduce inequities in the NZ oral health care system.
This study used a modified Delphi approach to understand different perspectives and to gain consensus agreement related to the management of deep caries and the application of vital pulp treatment (VPT) in NZ. It included an expert group from a range of dental fields who regularly manage deep caries. The goals of the study were to determine participants' baseline knowledge of deep caries and their clinical approach when managing deep caries. Further, feedback from clinicians sought to identify contextual factors that are important in a NZ setting to reduce disparities in health outcomes between different population groups.
This study was conducted over three rounds, and purposeful sampling identified clinicians (dental specialists, general dental practitioners and Māori oral health providers) who regularly manage patients with deep caries. In total, 28 clinicians currently registered with the Dental Council of New Zealand took part in this study, 18 general dental practitioners, two endodontic specialists, three paediatric dental specialists, two special needs dental specialists, one Māori oral health provider, one oral health therapist and one hospital-based community dentist. Participants were sent information between rounds outlining areas of disagreement and with educational resources from current international guidelines; and they were able to modify their responses based on the information provided. The consensus limit was set at 80%.
In the first round, an online questionnaire including Likert and open-ended questions was developed and validated for use to collect baseline information. The questions explored participants’ understanding of deep caries and VPT, management for patients with high- and low-caries risk, case selection, attitudes towards VPT procedures and awareness of international guidelines. The questionnaire was validated before being sent to participants.
The second round employed semi-structured interviews to enrich the data from round one and to clarify areas in the baseline questionnaire where there was disagreement. Further, interviews enabled researchers to gain a deeper understanding of socio-demographic factors that may impact an individual's oral health. Clinicians discussed the perceived caries risk factors and barriers to accessing treatment for the management of deep caries while also identifying gaps in their own knowledge, understanding and practice.
The third round involved developing consensus statements based on data gathered from the first two rounds of the study and international position statements. An online questionnaire consisting of ‘agree’ or ‘disagree’ statements was formulated, validated, and sent to all participants. Responses were gathered and statements that reached the predetermined consensus level of 80% were included in the guidelines.
Data from the first round revealed that participants had an individualised approach when managing deep carious lesions and there was no consistency irrespective of the field of practice. There was apprehension about adopting VPT procedures for symptomatic teeth and socio-demographic factors play a role in people's ability to access dental care. Consensus was reached among participants for all consensus statements but one where participants disagreed that a full pulpotomy was necessary to manage asymptomatic teeth with extremely deep caries. Context needs to be considered in the development of a NZ based guideline for the management of deep caries.
With the help of participants, this study has moved towards reducing the barriers between cariology and endodontics and gained consensus agreement on how deep caries can be managed with VPT in a NZ practice environment. This data has informed the development of a draft national guideline that uses a staged and evidence-based approach to encourage dentists to consider and offer patients conservative, biologically based techniques when managing deep carious lesions.