Cognizance and Use of Minimally Invasive Dentistry Approach by General Dentists: An Overlooked Companion.

BACKGROUND: Dental caries begins with the decalcification of the first nonorganic part, followed by the decay of the organic tooth matrix. Minimally invasive dentistry (MID) focuses on using the adhesive technique for restoration as these techniques allow minimum removal of healthy tooth structure.
OBJECTIVE: This study aimed to assess the attitude, knowledge, and behavior of the general dentists toward the use of MID and to evaluate if MID is considered as standard care measure among general dentists.
MATERIALS AND METHODS: This was a cross-section observational survey and included 285 practicing dentists. The survey questions were divided into two parts. The question related to the use of sharp explorer utilized response categories (1-5), with options of always, most of the time, often, sometimes, and never or rarely. The independent variables collected were age, gender, years of practice, clinical hours, type of practice, postgraduate education, and clinic environment. The data collected were tabulated and were statistically analyzed.
RESULTS: The results of the present study showed that MID meets the standard of care for the treatment of both primary teeth 85.96% (n = 245) as well as permanent teeth 78.24% (n = 223). ART, sandwich technique, in-office, and at-home topical fluoride application were considered active for treating dental caries. The use of sharp explorers, nonsharp explorers, radiographs, and magnification were considered common for caries detection.
CONCLUSION: The more dentists who listened to about MID in the past responded that the MID concept is the standard of care for the treatment of primary and permanent teeth than dentists who have heard little or nothing about MID. Copyright:

INTRODUCTION

Dental caries is one of the most common, most prevalent, persistent, and costly oral infectious diseases affecting the population worldwide. Dental caries is caused by bacterial colonization. Caries begins with the decalcification of first the nonorganic part, followed by the decay of the tooth organic matrix.[1] The exo-polysaccharide-rich biofilm matrix formation and persistent low pH (due to acidification) at the tooth-biofilm interface are major virulence factors that modulate and control the dental caries pathogenesis.[2] Dental caries prevalence of total and untreated cases in permanent/primary teeth among the age group of 2–19 years was found to be 45.8 and 13.0%, respectively, according to the National Health and Nutrition Examination Survey 2015–2016.[3] Dental caries contributes one of the main reasons for replacement and placement of restorations. The demineralization seen in dental caries is attributed to the consumption of starchy and sugary food and beverages along with inadequate salivary flow, poor oral hygiene, and less fluoride exposure.[45]

With the advancement in surgical instruments and techniques, use of adhesive restorative materials and advanced techniques for caries restoration and prevention were advocated and famous. To minimize the size of the prepared cavity, the use of the adhesive restorative materials was advocated in the minimal intervention paradigm.[67] Majority of dentists continue to use the conventional treatment strategies for the treatment of dental caries rather than the modern adhesive restorative protocols focusing on preserving the healthy tooth structure.[89]

Minimally invasive dentistry (MID) includes different techniques which including chemomechanical systems, hand instrumentation, laser cavity preparation, and air abrasion.[1011] Atraumatic restorative technique (ART) is one of the MID techniques including hand instrumentation.[1213]

Laser cavity preparation utilizing the hydrokinetic systems is another MID technique, which cuts hard tissues and fissure sealing as well as removes soft caries.[14] Glass-ionomer cement (GIC) has adhesive properties and fluoride release along with other ions like calcium into saliva and teeth are favorable properties of GIC. It also uptake fluoride released from dentifrices.[15]

With the advancements in new technologies, newer studies were aimed to increase the saliva flow and calcium and phosphate concentration in the dental plaque.[16] Xylitol and chlorhexidine are also being used for caries treatment which is safe, although diarrhea is reported with large doses.[17]

Public health/community dentistry is focused on diagnosis, prevention, and control of various dental problems and also aims at promoting oral health via education, promotion, research-based strategies, and dental health-care programs. Very scarce data in the literature are available regarding MID and its use by the general dentists.[10]

The present survey study aimed at assessing the attitude, knowledge, and behavior of the general dentists toward the use of MID. Furthermore, the study evaluated whether MID is considered as standard care measure among general dentists and to identify factors that associate with the dentist's belief of using MID as a standard care tool. Factors influencing the use of sharp explorers for caries detection were also focused on the study.

MATERIALS AND METHODS

The study included the 285 dentists who agreed to participate in the survey and who were practicing at the time of the survey.

The survey questions were divided into two sections. One section was based on the general knowledge and familiarity of the practicing general dentists with the MID approach. The responses of the participants were recorded in the form of numbering 1–5 for questions related to the use of various MID techniques. Many responses were in terms of if they ever agreed or have used the mentioned specific techniques.

The question related to the use of sharp explorer utilized response categories (1–5), with options of: always (100%), most of the time (75%–99%), often (50%–74%), sometimes (10%–49%), and never or rarely (0%–9%). If responders answered always, most of the time, and often, these responses were counted as a yes, whereas sometimes and never or rarely were considered a no answer.

The independent variables collected in the present cross-sectional observational study were age, gender, years of practice, clinical hours, type of practice (government or private), postgraduate education, and clinic environment. The data collected were tabulated and were statistically analyzed.

RESULTS

A total of 372 general dentists were approached to respond to the survey. The demographic characteristics of the study subjects are presented in Table 1.

Table 1

Demographic data of the study responders

Variable	n (%)
Age (years)
30 or younger	95 (33.33)
35–55	99 (34.73)
55 or older	91 (31.92)
Gender
Male	152 (53.33)
Female	133 (46.66)
Postgraduate training
Yes	137 (48.07)
No	148 (51.92)
Years of practice
<5	120 (42.10)
5–10	97 (34.03)
>10	68 (23.85)
Dental specialty
Community dentistry	10 (7.29)
Pediatric dentistry	33 (24.0)
Oral surgery	15 (10.94)
Endodontics	26 (18.97)
Orthodontics	17 (12.40)
Periodontics	12 (8.75)
Oral medicine and radiology	9 (6.56)
Prosthodontics	8 (5.83)
Oral pathology	1 (0.72)
Practice hours (per day) (h)
Up to 3	87 (30.85)
3–5	63 (22.10)
5–8	76 (26.66)
>8	59 (20.70)
Frequency of organizing dental camps (per year) (camps)
<5	168 (58.94)
5–10	45 (15.78)
>10	72 (25.26)
Number of patients per week (average)
1–49	49 (17.19)
50–99	78 (27.36)
100–249	37 (12.98)
>250	121 (42.45)

Responses of the study participants were also recorded in terms of the MID training. Various questions that were asked included if the responders were aware of the MID or ever heard about it, to which 95.08% (n = 271) were aware of MID [Table 2].

Table 2

Awareness about minimally invasive dentistry in the study responders

Variable	n (%)
Aware of MID
Yes	271 (95.08)
No	14 (4.91)
Training/certification/CDE on MID
Yes	131 (45.96)
No	154 (54.03)
Form of training received
Didactic	65 (49.61)
Hands-on	8 (6.10)
Both	42 (32.06)
Others	16 (12.21)
MID – standard care for treatment of primary teeth
Yes	245 (85.96)
No	40 (14.03)
MID – standard care for permanent teeth
Yes	223 (78.24)
No	62 (21.75)
Sharp explorer for caries detection
Always (100%)	80 (28.07)
Most of the time (75%–99%)	65 (22.80)
Often (50%–74%)	69 (24.21)
Sometimes (10%–49%)	40 (14.03)
Never or rarely (0%–9%)	31 (10.87)

MID: Minimally invasive dentistry, CDE: Continuing dental education

Table 3 shows that the responses of the general dentists on questions regarding the effectiveness of different MID assessed in the survey were Atraumatic Restorative treatment, sandwich technique (utilizing GIC + composite), in-office application of the fluoride varnish, and topical high-concentration fluoride application at home. Responses by the general dentists concerning the effectiveness of different MID techniques for caries treatment in primary teeth were recorded [Table 3].

Table 3

Responses for minimally invasive dentistry techniques by general dentists

Variable	Very effective, n (%)	Effective, n (%)	Ineffective, n (%)	Highly ineffective, n (%)	Unaware of this technique, n (%)
Primary teeth
ART	66 (23.15)	137 (48.07)	23 (8.07)	8 (2.80)	51 (17.89)
Sandwich technique	57 (20)	154 (54.03)	17 (5.96)	6 (2.10)	51 (17.89)
Fluoride varnish	68 (23.85)	176 (61.75)	20 (7.01)	11 (3.85)	10 (3.50)
Topical high-concentration fluoride at home	20 (7.01)	140 (49.12)	45 (15.78)	11 (3.85)	69 (24.21)
Permanent teeth
ART	31 (10.87)	134 (47.01)	45 (15.78)	14 (4.91)	61 (21.40)
Sandwich technique	26 (9.12)	131 (45.96)	34 (11.92)	9 (3.15)	85 (29.82)
Fluoride varnish	60 (21.05)	171 (60)	8 (2.80)	6 (2.10)	40 (14.03)
Topical high-concentration fluoride at home	43 (15.08)	191 (67.01)	45 (15.78)	6 (2.10)	0

ART: Atraumatic restorative treatment

DISCUSSION

A total of 372 general dentists practicing at the time of the survey in either private or public sectors were contacted to respond to the survey. However, 75.2% (n = 285) among the approached 372 gave consent and responded. The rest (87) did not agree to participate; the reason given by all was lack of time. Overall, 53.33% of the study respondents were male and 46.66% were female. Dentists with postgraduate training were 48.07% of respondents, which was consistent to study by Gaskin et al. who reported that 58.1% of respondents completed postgraduate training.[1718]

Concerning the results of the present study, 75.08% of responders use this approach sometime or other.[19] Traumatic defects on hard tissue leading to future caries lesions[19] do not improve caries diagnosis accuracy[2021] and consistency.

The effectiveness of these techniques in permanent teeth was reported to be 10.87% for ART, 9.12% for the sandwich technique, and 21.05% and 15.08% for in-office and at-home fluoride application, respectively. This can be explained by the fact that ART, fluoride varnish, and sandwich techniques are more commonly employed in primary teeth than adults. Previous studies in the literature have reported that MID concepts and techniques including the use of fluoride varnish, chlorhexidine, pit-and-fissure sealants, and resin base composite restoration have been used in the recent past.[2223]

CONCLUSION

MID meets the standard care of treatment for primary and permanent teeth in the belief of the practicing general dentists. The factors that relate to MID as the standard of care were dentist agreement for knowledge about MID and consideration that fluoride varnish is efficacious. To conclude, the present observation survey suggests that there is a paradigm shift from conventional treatment toward the MID concept.

Hence, further studies in future with more study subjects from different geographical areas and logger monitoring periods are required to gain further insight into the MID use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.