Received: 8 November 2019

| Revised: 17 January 2020

| Accepted: 9 March 2020

DOI: 10.1111/ipd.12639

ORIGINAL ARTICLE

Dentists' decisions for deep carious lesions management in

primary teeth

Michèle Muller-Bolla1,2,3 | Anaïs Garcia2 | Elody Aïem1,2 | Sophie Doméjean4

1
Department of Paediatric Dentistry,
Faculty of Dentistry, Côte d’Azur
University, Nice, France
2
Paediatric Dentistry, CHU Nice, Nice,
France
3
Laboratory URB2i – EA 4462, Paris
Descartes University, Paris, France
4
UFR Odontology, CROC EA 4847,
Clermont Auvergne University, CHU
Clermont-Ferrand, France
Correspondence
Michèle Muller-Bolla, Faculté Chirurgie-
Dentaire, Pôle St Jean Angély, 24 av des
Diables Bleus, 06 357 Nice Cedex 4,
France.
Email: michele.muller@univ-cotedazur.fr
Abstract
Background: Questionnaire surveys have been undertaken worldwide to investigate
practices and knowledge related to deep carious lesion (DCL) management in perma-
nent teeth, and there is a lack of data in primary teeth.
Aim: A cross-sectional questionnaire survey was undertaken to describe the manage-
ment strategies for DCL of vital primary teeth, focusing on the different caries re-
moval techniques, among dentists practicing pediatric dentistry (DPPDs) in France.
Their behavior was compared to members one registered to European Academy of
Pediatric Dentistry (EAPD).
Design: A questionnaire was electronically administrated (2018–2019) to members
of the Collège des Enseignants en Odontologie Pédiatrique (CEOP), the Société
Française d’Odontologie Pédiatrique (SFOP), and the EADP. Descriptive and sta-
tistical analyses were performed.
Results: Response rate was, respectively, for CEOP, SFOP, and EAPD about 74%,
29%, and 15%. About half of the respondents (53%) would perform a complete car-
ies removal into one step when 12% would indicate a stepwise technique: 68% of
the DPPDs practicing in France would perform complete caries removal in one step
when the preferred option in the other EAPD members was the selective excavation
(44%) (P < .001).
Conclusions: Complementary education of French dentists in the domain of caries
management appears necessary regarding current recommendations.

KEYWORDS
deep carious lesion management, Europe, France, primary teeth, questionnaire survey

1 | IN T RO D U C T ION showed a great variability of its implementation in adult

Preserving healthy and mineralizable tissue, achieving a re-
storative seal, maintaining pulpal health, and maximizing
restoration success are the objectives of the management
of deep carious lesions (DCL) in vital teeth.1 Selective car-
ious tissue removal is highly recommended in permanent
teeth1,2; nevertheless, surveys investigating dental practices
patients.3-5
Literature (clinical studies and systematic reviews) com-
paring caries removal techniques (selective caries removal
(SCR), complete caries removal (CCR), and stepwise caries
removal technique (SWT-CCR into two steps)) in primary
teeth is sparse.6-8 Complementary researches were systemati-
cally proposed in these particular cases and recommendations

© 2020 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Int J Paediatr Dent. 2020;00:1–9.  wileyonlinelibrary.com/journal/ipd | 1

2
|    MULLER-BOLLA et al.
are proposed by extension of those focused on permanent
teeth1,9-12 (Table 1). Primary and permanent teeth, however,
have morphological and histological differences, such as thin-
ner dentine with numerous large tubules and a proportionally
larger pulp chamber in primary teeth. These particularities
could contribute to faster progression of caries in these teeth
also characterized by a limited life span.13
If questionnaire surveys have been undertaken to investi-
gate various aspects of caries management in primary teeth,
there is a lack of data regarding the particular case of DCL
management.14-19 A cross-sectional questionnaire survey was
thus undertaken to describe the management strategies for
DCL of vital primary teeth, focusing on the different caries
removal techniques, among dentists practicing pediatric den-
tistry (DPPDs) in France. Their behavior was compared with
members' behavior registered with the European Academy of
Pediatric Dentistry (EAPD).
2 | M AT E R IA L A N D ME T H O DS
2.1 | Questionnaire survey
Protocol and questionnaires (in French for the French part
of the survey, in English for other European countries)
were approved by the French ad hoc ethic committee, the
‘Commission Nationale Informatique et Liberté’ (CNIL) (#
UNS-E18-006).
2.2 | Study population
The study population consisted in the DPPDs practicing in
France and other European DPPDs registered to EAPD. The
questionnaire was administrated to three different lists of
practitioners:
• the DPPDs practicing in France approached in two ways:
○ the French national association of teachers in pedi-
atric dentistry (CEOP: Collège des Enseignants en
Odontologie Pédiatrique) (n = 92) (some teachers may
work part are as private practitioners not only focused
on pediatric dentistry);
○ the subgroup of private dental practitioners treating
exclusively children in French Society of Pediatric
Dentistry, Société Française d’Odontologie Pédiatrique
(SFOP) (n = 185).
• the other European DPPDs contacted through the EAPD
(n = 1002).
All these DPPDs (DPPDs practicing in France and other
EAPD members) do not have systematically an exclusive or
specialized practice in pediatric dentistry.
Why this paper is important to paediatric
dentists
• There are wide disparities between dentists prac-
ticing pediatric dentistry in France or registered
to EAPD in terms of deep carious lesion manage-
ment in vital primary teeth.
• Despite complete caries removal into one step has
been shown to be iatrogenic in deep carious lesion
in vital teeth, about half of the respondents would
perform it systematically.
• Continuing education seems to be necessary to
promote practice evolution toward deep carious
lesion management in vital primary teeth.
2.3 | Questionnaire
A questionnaire was developed specifically for this survey;
it was based on a questionnaire related to caries manage-
ment in adults.3 The French version was firstly developed
and was subject to minor adjustments after pilot testing on
10 DPPDs. This was secondly translated into English (MMB
and SD), and the English version received the approbation of
the EADP scientific board.
The questionnaire was divided into five sections related,
respectively, to demographic data (gender, graduation year,
country, type of practice), clinical decisions (management
strategies for DCL in vital primary teeth), clinical protocols
(methods for carious tissue removal, criteria to assess carious
tissue removal in DCL, preferred treatment for an exposed
pulp, preferred liner or base material used for different indi-
cations), dentists’ knowledge about allowing carious dentine
to remain under a restoration based on four questions, and
a particular clinical case on the lower right second tempo-
rary molar. Binary or multiple-choice questions with closed
responses were used; a five-point Likert scale was also
proposed.
The questionnaire was administrated anonymously and
electronically via SurveyMonkey®. The link was sent twice
by e-mail to all the EAPD, CEOP, and subgroup SFOP mem-
bers from December 2018 to March 2019. It was sent with a
e-cover letter explaining the purpose of the study.
2.4 | Statistical analysis
Descriptive analyses were undertaken. Statistical compari-
sons of groups were performed using independent sample
t test or chi-squared analysis: respondents and total mem-
bers of different associations, DPPDs practicing in France
and EAPD members, or different methods used for caries
MULLER-BOLLA et al.   
| 3

removal (SCR, SWT, and CCR). ANOVA allowed compar-
ing year of graduation (mean ± SD) for the three carious tis-
sue removal techniques (SCR, SWT, and CCR). Univariate
logistic regression analyses were performed to test predictors
of clinical decisions transformed into binary variable (SCR/
CCR). Multivariable logistic regression analyses were then
conducted, with predictors being entered and then removed
stepwise if P > .10 (hierarchical method). Odds ratios (OR)
and 95% confidence intervals (95% CI) were calculated as
effect estimates. For all analyses, the level of significance
was set at 0.05. Data were analyzed using the SPSS computer
software (SPSS version 20, IBM, Armonk, USA).
3 | R E S U LTS
After exclusion of two respondents from France and one from
EAPD due to incomplete questionnaires, response rates were,
respectively, 74% (n = 68), 29% (n = 53), and 15% (n = 149)
for dentists registered to CEOP, subgroup SFOP, and EAPD.
French and EAPD respondents were, respectively, represent-
ative of CEOP, subgroup SFOP, and EAPD (Table 2). Three
respondents from France were excluded from EAPD data as
they answered the EAPD questionnaire. Thus, the analyzed
data concerned 99 dentists practicing in France and 146
EAPD members because 22 French dentists were members
of both CEOP and SFOP.
Table 3 summarizes the respondents’ demographic char-
acteristics. Dentists practicing in France graduated more
recently than EAPD members (P = .008) and French respon-
dents practicing in an educational environment were more
numerous than the others (P = .005). On the contrary, the
proportion of dentists with exclusive or specialized practice
in pediatric dentistry was lower in France than among EAPD
members (P = .011). In Europe, a university teacher working
in departments of pediatric dentistry has not systematically
an exclusive or specialized practice in pediatric dentistry.
Indeed, in France, among the 68 respondents involved in den-
tal education, 25% (n = 17) were also general private prac-
titioners; in the same manner, 10% (n = 7) of the 71 EADP
members involved in dental education were so.
3.1 | Clinical decisions for carious
tissue removal
About half of the respondents (n = 129) would perform a
CRR in one step when 12% (n = 31) would prefer a SWT.
Among those who would perform a SWT, 45% (n = 14)
would wait for six weeks to three months between both

TABLE 1 Recommendations focusing on deep carious lesions in vital primary teeth

Recommendations
NHS (National Health Choose the least invasive, feasible caries management strategy, taking into account: the time to exfoliation, the site
Service), 20189 and extent of the lesion, the risk of pain or infection, the absence or presence of infection, preservation of tooth
structure, the number of teeth affected, avoidance of treatment—induced anxiety (Strong recommendation; low
quality evidence):
In occlusal advanced carious lesion: selective (partial) caries removal and restoration (alternative options: Hall
technique, non-restorative cavity control).
In proximal advanced carious lesion: the Hall technique is considered as the preferred treatment option; selective
caries removal and restoration or non-restorative cavity control are considered as alternative options due to a lack of
supporting evidence.
In anterior advanced carious lesion: selective or complete caries removal and restoration (alternative options: non-
restorative cavity control).
AAPD (American Indirect pulp treatment (IPT) is synonymous of partial caries removal. It is one of the three vital pulp therapies (IPT,
Academy Pediatric direct pulp cap, pulpotomy) considered in vital primary teeth with deep caries lesions.
Dentistry), 201710 The panel was unable to make a recommendation on superiority of any particular type of vital pulp therapy owing to
lack of studies directly comparing these interventions.
Consensus In deeper lesions, in teeth with sensible (vital) pulps, preserving pulp health should be prioritized over ‘mechanical’
recommendations on restoration success, while in shallow or moderately deep lesions, restoration longevity might be considered the more
minimally invasive important factor.
caries removal, -For teeth with shallow or moderately deep lesions, ‘selective removal to firm dentine’ excavation protocols should
2016,1 201711 be followed.
-In deep lesions (radiographically extending into pulpal third or quarter of the dentine), ‘selective removal to soft
dentine’ should be performed.
SIGN (Scottish If complete caries removal is not possible, an indirect pulp capping technique should be considered (a calcium
Intercollegiate hydroxide containing lining material, followed by an adhesive restoration or a preformed metal crown) should be
Guidelines Network), used.
200512
 4
|    MULLER-BOLLA et al.

dental visits when 29% (n = 9) and 26% (n = 8) would wait,

0.980
0.160
respectively, for 3-6 months and more than six months. The

P
graduation years (mean ± SD) of the respondents did not
significantly differ for the three carious tissue removal tech-

828/174 (83/17%)
255/747 (26/74%)
niques (P = .865) (for CCR: 2 000.61 ± 13.03; for SWT:
Total (n = 1002)

No data available

Not applicable
1 999.32 ± 14.43 and for SCR: 2 000.64 ± 10.98). EAPD
members performed more frequently SCR compared with
DPPDs practicing in France (P < .001) while clinical deci-
sions were not influenced by type of practice (Table 4).

123/26 (83/17%)
46/103 (31/69%)

3.2 | Protocols for carious tissue removal

Not applicable
Respondents

Note: CEOP, Collège des Enseignants en Odontologie Pédiatrique: French national association of teachers in pediatric dentistry; EAPD, European Academy of Pediatric dentistry.
(n = 149)

1999 (12)

Both hand excavator (87%) and metal bur (60%) were the
EAPD

most cited tools for dentine excavation. Compared with

EAPD members, DPPDs practicing in France had ten-
dency to prefer burs and more particularly ceramic burs
Sociodemographic comparison of CEOP members, French practitioners treating exclusively children and EAPD members

0.697

(P < .001). Dentine hardness was the most cited criterion for
P

assessing the limit of carious tissue even if the carious den-

tine concerned by excavation significantly varied between
No data available
34/151 (18/82%)

DPPDs practicing in France and EAPD members (P < .001)

Total (n = 185)
French dentists treating exclusively

Not applicable

(Table 5). Following caries removal, 51% (n = 124) of the

respondents would place a lining underneath the permanent
adhesive restoration. In cases of pulpal exposure during exca-
vation, the treatment choice was direct pulp capping (n = 14;
6%), pulpotomy (n = 215; 88%), pulpectomy (n = 5; 2%), or
extraction (n = 11; 4%). In decreasing order of frequency,
11/42 (21/79%)

Not applicable
Respondents

was suggested the use of Biodentine™/mineral trioxide ag-

2007 (12)
childrena

(n = 53)

gregate (MTA) (n = 98; 42%), intermediate restorative mate-

Subgroup in French Society of Pediatric Dentistry: Société Française d’Odontologie Pédiatrique, SFOP.

rial (IRM) (n = 72; 31%), calcium hydroxide (n = 24; 10%),

or a combination of the above (n = 40; 17%). Concerning the
clinical case (Figure 1), 49% (n = 120), 28% (n = 69), 18%
0.734
0.993

(n = 7), and 15% (n = 38) of the respondents indicated, re-

P

spectively, SCR, CCR, SWT, and pulpotomy or pulpectomy.

A multivariable model (adjusted logistic regression) was
constructed to assess the bivariate dependent variable ‘pre-
No data available

21/71 (23/77%)
27/65 (29/71%)
Total (n = 92)

Not applicable

diction of clinical decision’: only group membership permit-

ted to predict clinical decision (Table 6) with higher rate of
SCR among EAPD members.

3.3 | Knowledge of the respondents about

CEOP (France)

14/54 (21/79%)
20/48 (29/71%)

Not applicable

leaving carious dentine under a restoration

Respondents

2002 (13)
(n = 68)

For the majority of respondents, CCR was not necessary

to prevent further caries progression under the restoration
(n = 163; 67%) and a certain amount of cariogenic micro-
Gender, male/female

organisms can be left, since intact restorations can seal cari-

France, Paris/others

Country, European/
non-European (%)
Year of graduation

ous lesions and thus arrest the caries process (n = 215; 88%).
Moreover, respondents disagreed that caries should always
mean (SD)
TABLE 2

be removed completely, since residual caries is a risk for the

vitality of the pulp (n = 182; 74%) and that caries in proxim-
(%)
(%)

ity to the pulp should be left to avoid pulp exposure (n = 196;

a
MULLER-BOLLA et al.   
| 5

TABLE 3 Demographic comparison

DPPDs practicing in EAPD (except French
of dentists practicing pediatric dentistry
France (n = 99) members) (n = 146) P
(DPPDs) in France and EAPD members
(without French members) Gender male/female (%) 23/76 (23/77%) 43/103 (29/71%) 0.282
Mean year of graduation (SD) 2003 (13) 1999 (12) 0.008
Type of practice, private/ 27/47/25 (27/48/25%) 42/56/48 (29/38/33%) 0.307
salaried/mixed (%)
Type of practice, university 68/3/28 (69/3/28%) 71/14/61 (49/9/42%) 0.005
hospital/hospital/other (%)
Type of practice, exclusive 79/20 (80/20%) 133/13 (91/9%) 0.011
or specialized practice in
pediatric dentistry/general (%)
Note: EAPD, European Academy of Pediatric Dentistry; SD, standard deviation.

80%). The responses of the PDs practicing in France did not
differ from EAPD members’ ones (Table 7).
4 | D IS C U SSION
Less invasive strategies for managing DCL in vital primary
teeth were not widely observed in our study. DPPDs practic-
ing in France preferred CCR whereas EAPD members were
more numerous to indicate SCR. Concerning all the respond-
ents, only 35% indicated SCR.
This questionnaire survey is the first of its kind to assess
DCL management in primary teeth and to compare behav-
iors and knowledge between DPPDs practicing in France and
other EAPD members. The sample has good external validity
as respondents were representative of the study populations in
terms of gender, area, or country (Table 2). Nevertheless, the
study does have limitations as it was not possible to assess the
representativeness in terms of age or year of graduation and
type of practice as this information could not be shared by the
CEOP, SFOP, and EADP. The response rate of the DPPDs
practicing in France was higher compared with that obtained
by EAPD members. The respondents’ professional charac-
teristics varied significantly between France and the other
countries (EAPD data). This might be due to the non-uni-
form European situation concerning the pediatric dentistry;
the specialty exists in only 11 EU countries (Bulgaria,
Croatia, Finland, Hungary, Italy, Lithuania, Poland, Portugal,
Romania, Slovenia, and Sweden). In France, only some ex-
clusively private DPPDs are identified by social networks
(subgroup SFOP) in complements to CEOP members; so,
respondents practicing in France were more likely to have a
general practice.20 In consequence, pediatric dentistry teach-
ers were more numerous in France whereas salaried or private
DPPDs were proportionally more numerous among EAPD
members (Table 3). Selection bias is therefore likely, with

TABLE 4 Methods used for caries tissue removal in deep lesions of vital primary teeth

Complete caries removal in one Complete caries removal in two

step steps Selective caries removal
n = 129 (53%) n = 31 (12%) n = 85 (35%) P
a
France/EAPD (%) 69/60 (68/41%) 9/22 (9/15%) 21/64 (21/44%) <0.001
Gendermale/female 31/98 (47/55%) 9/22 (14/12%) 26/59 (39/33%) 0.549
(%)
Type of practice, 42/48/39 (61/47/53%) 7/14/10 (10/14/14%) 20/41/24 (29/40/33%) 0.466
private/salaried/mixed
(%)
Type of practice, 77/5/47 (55/29/53%) 16/5/10 (12/29/11%) 46/7/32 (33/41/36%) 0.227
university hospital/
hospital/other (%)
Type of practice: 107/22 (51/67%) 26/5 (12/15%) 79/6 (37/18%) 0.100
exclusive or
specialized in
pediatric dentistry/
general (%)
a
France/EAPD: dentists practicing pediatric dentistry in France/EAPD members without French members.
6
|    MULLER-BOLLA et al.

TABLE 5 Criteria and instruments used for carious tissue removal in deep carious lesions of vital primary teeth

DPPDs practicing in France EAPD (except French members)

(n = 99) (n = 146) P
Hardness Soft 0 (0%) 14 (10%) <0.001
Leathery 15 (15%) 49 (34%)
Firm 59 (60%) 53 (36%)
Hard 18 (18%) 22 (15%)
Not relevant 7 (7%) 8 (5%)
Color Heavily stained 12 (12%) 19 (13%) 0.961
Normal to yellow 27 (27%) 41 (28%)
Not relevant 60 (61%) 86 (59%)
Excavation methods Metal bur, yes/no (%) 67/32 (68/32%) 81/65 (56/44%) 0.055
Ceramic bur, yes/no (%) 46/53 (47/53%) 27/119 (19/81%) <0.001
Hand excavator, yes/no (%) 89/10 (90/10%) 125/21 (86/14%) 0.322
Chemo-mechanical, yes/ 10/90 (10/90%) 31/115 (21/79%) 0.022
no (%)
Note: DPPDs, dentists practicing pediatric dentistry.

non-respondents differing demographically, by healthcare

(a)
(b)
F I G U R E 1 In a 5-year-old child who has never experienced
any pain and whose caries risk is currently under control, what is,
according to you, the best therapeutic option for tooth 85? Complete
caries excavation in one step vs partial/selective caries excavation
versus complete caries excavation in two steps (stepwise excavation)
vs pulpotomy vs pulpectomy?
system and, possibly, in their behavior and attitude toward
the management of carious lesions. The present results, how-
ever, give an indication of dentists’ decisions and knowledge
of deep carious lesions in primary teeth. While it would have
been useful to contact non-respondents to follow-up on the
questionnaire, this was not possible since the questionnaires
were by law anonymous as required by French regulations.
Table 1 clearly shows that recommendations vary markedly
between dental associations and scientific societies. Moreover,
the term ‘indirect pulp capping’ in the American Dental
Association (ADA) recommendations was interpreted as some-
thing different than intended (SCR) by others (Table 1); this
could explain the low SCR rates observed in our results. Other
explanations are plausible. In the light of the results of the mul-
tivariable analysis (Table 6), it can be hypothesized that French
respondents compare poorly with their foreign colleagues for
caries management.21 Lastly, if SCR excavation in permanent
teeth is clearly supported by evidence,2,22 this was not the case
in primary teeth. Recent systematic reviews demonstrated that
the risk of pulpal exposure is higher with CCP compared with
SCR in primary teeth and that pulpo-periodontal complications
do not significantly differ between these two caries removal
strategies.6,8,23,24 Finally, restoration longevity in primary teeth
appears to be longer following CCR than SCR.8,25 Only 35%
of the respondents indicated SCR; this could be explained by
the lack of consensus and the contradictory results found in the
literature; moreover, this may be linked to the fact that a large
proportion (57%) of the respondents were academics practicing
in university hospitals (Table 3). Some doubt could be raised
concerning dentists’ knowledge about leaving carious dentine
MULLER-BOLLA et al.   
| 7

TABLE 6 Regression logistic analyses

Partial caries Complete caries

removal removal
Crude Adjusted
Independent variables n (%) n (%) OR (95%) OR (95%)
Groups DPPDs practicing in 21 (21%) 78 (79%) 1 1
France
EAPD (except 64 (44%) 82 (56%) 2.90 (1.62-5.19)**** 2.71 (1.51-4.89)****
French members)
Gender Male 26 (39%) 40 (61%) 1 Not included
Female 59 (33%) 120 (67%) 0.76 (0.42-1.36)
Type of practicea Private 20 (29%) 49 (71%) 1 Not included
Salaried/mixed 65 (37%) 111 (63%) 1.44 (0.79-2.62)
b
Practice University hospital 46 (33%) 93 (67%) 1 Not included
Other 39 (37%) 67 (63%) 1.18 (0.69-2.00)
Type of practice Specialized or 79 (37%) 133 (63%) 1 1
exclusivec
General 6 (18%) 27 (82%) 0.37 (0.15-0.95)** 0.45 (0.18-1.17)
Note: DPPDs, dentists practicing pediatric dentistry; OR, bivariate odds ratio; 95% CI, 95% confidence interval.
a
Dentists without exclusive private practice were mixed together.
b
Practice ‘other’ corresponded to non-university hospital practice.
c
Specialized or exclusive practice in pediatric dentistry.
*P < .10, **P < .05, ***P < .01, ****P < .001.

TABLE 7 Dentists’ knowledge about leaving carious dentine under a restoration

EAPD (except French members)

PDs practicing in France (n = 99) (n = 146)

Disagreea Agreea No opinion Disagreea Agreea No opinion P

Cariogenic microorganisms need to be 69 (70%) 28 (28%) 2 (2%) 94 (64%) 46 (32%) 6 (4%) 0.524
removed completely, since caries might
progress otherwise
Certain amount of cariogenic 7 (7%) 91 (92%) 1 (1%) 19 (13%) 125 (86%) 1 (1%) 0.302
microorganisms can be left, since intact
restorations can seal and thus arrest
cariesa
Caries should always be removed 72 (73%) 25 (25%) 2 (2%) 110 (75%) 26 (18%) 10 (7%) 0.109
completely, since residual caries is a risk
for the vitality of the pulp
Caries in proximity to the pulp should be 16 (16%) 80 (81%) 3 (3%) 22 (15%) 116 (80%) 8 (6%) 0.655
left to avoid pulp exposure
a
The following merging was done for statistical purpose: agree/strongly agree versus disagree/strongly disagree versus no opinion.

under a restoration but the type of tooth (primary or permanent)
was not clearly mentioned in the questions (Table 7). Indeed,
there were contradictions in some answers. Considering the
clinical case (Figure 1), the proportion of respondents who sug-
gested SCR increased to 50%. This could be due to a lack of an
agreed definition of DCL; Schwendicke et al3 have already dis-
cussed this point, knowing that for some, a lesion is deep when
it reaches the inner third of dentine but for others, the threshold
is placed at the inner quarter of dentine.1 In primary molars, the
pulp chamber is proportionally larger than in permanent teeth:
pulp horns are more prominent, the dentine thickness is less,
and the risk of pulpal exposure during carious dentine excava-
tion is higher.13
Dentine hardness appeared to be the main criterion used
for carious tissue removal in DCL in primary teeth—the
same tendency has been described among French, German,
and Norwegian general practitioners concerning perma-
nent teeth3 (Table 6). Nevertheless, DPPDs practicing in
8
|    MULLER-BOLLA et al.
France seem to be more aggressive compared with EAPD
members because soft dentine (excavated with minimum
resistance using hand instruments)26 was systematically re-
moved. On the other hand, color was not often used by re-
spondents. Following SCR, there was absence of consensus
among respondents regarding the need for a lining placement
underneath the permanent adhesive restoration. This is in
accordance with AAPD guidelines, which do not clearly rec-
ommend a liner because the success of IPT in vital primary
teeth with DCL was independent of the type of biomaterial
used (bonding agent, calcium hydroxide liners).10
The low proportion of respondents suggesting SWT (13%)
could be explained by different authors that brought up the
question of the necessity of the second stage for removing the
remaining carious tissue, especially since the SCR was con-
sidered less costly at similar efficacy compared with SWT at
one year of follow-up.27
Concerning CCR assessed in our study, this caries removal
method seemed more frequently used in primary teeth (53%)
than in permanent teeth (47%), according to the meta-analy-
sis of Schwendicke et al. (Table 4).6 Considering both SWT
and CCR, most of the respondents (65%) aimed for com-
plete excavation of carious tissue near the primary tooth pulp
(Table 4). The lack of respect of minimal intervention prin-
ciples in primary teeth could be explained by the limited life
span of these teeth or the difficulty of vital tooth diagnosis in
younger children (children or parents have often difficulty to
reporting symptoms). More recently, pulpotomy was easily
indicated in DCL. A recent systematic review comparing in-
direct pulp capping and pulpotomy identified only one trial28
whereas another systematic review29 concluded that there
was no clear treatment option for the treatment of extensive
tooth decay in primary teeth. The frequent choice of pulpot-
omy after iatrogenic pulpal exposure (88%) during excavation
confirmed this tendency. The more frequent Biodentine™ or
MTA choice appeared wise regarding evidence in the liter-
ature.10 In this study, formocresol has not been proposed as
an option as it is forbidden in France. On the contrary, the
AAPD strongly recommends the use of formocresol in pul-
potomy due to pulp exposure during carious dentin removal
in vital primary teeth with DCL. Lastly, 10% of respondents
suggested the calcium hydroxide while the AAPD condition-
ally recommends against its use for pulpotomy.10
If complementary education of French dentists in the do-
main of minimal intervention in caries management appears
necessary regarding recommendations, the evidence is still
insufficient for DCL in particular cases primary teeth with
limited life span. Further randomized controlled trials com-
paring the three caries removal techniques (CCR, SCR, and
SWT) in primary teeth and investigating pulpo-periodon-
tal complications over time, with a minimum follow-up of
3 years, are necessary to develop evidence-based clinical
guidelines.
ACKNOWLEDGMENTS
None.
CONFLICT OF INTEREST
MMB, AG, EA, and SD have nothing to disclose.
AUTHOR CONTRIBUTIONS
MMB and SD conceived the ideas; AG collected the data;
MMB analyzed the data; and MMB, AG, EA, and SD led the
writing together.
ORCID
Michèle Muller-Bolla https://orcid.
org/0000-0003-2811-5339
Elody Aïem https://orcid.org/0000-0003-1306-783X
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How to cite this article: Muller-Bolla M, Garcia A,
Aïem E, Doméjean S. Dentists' decisions for deep
carious lesions management in primary teeth. Int J
Paediatr Dent. 2020;00:1–9. https://doi.org/10.1111/
ipd.12639