INTRODUCTION

With increasing scientific and technological development in dentistry, new strategies are being employed with the goal of maximal conservation and minimal intervention in dental tissues affected by carious lesions¹. The optimal limits of carious tissue removal and the possibility of ever less invasive methods to arrest and control the development of caries are being discussed in the literature^2-9.

The many possibilities for invasive or conservative treatment of dental caries at its various stages are a source of doubt among dental practitioners as to which clinical approach should be adopted; as no scientific consensus has been reached, there is no one standard of care to follow¹⁰. These doubts, associated with the risks of false-positive and false-negative diagnoses, may lead to adoption of irreversibly invasive treatment approaches, particularly when treating primary teeth, the tissues of which are less mineralized and thinner than those of permanent teeth¹¹.

The Brazilian municipality of Campina Grande, state of Paraíba, has 49 oral health teams working within the framework of the Family Health Strategy (Estratégia de Saúde da Família, ESF). According to the Brazilian Ministry of Health's Department of Primary Care, these teams cover a population of approximately 341,550. Within this context, the present study sought to assess the approaches adopted by primary care dentists in this municipality when faced with carious lesions in the primary dentition. The objective was to ascertain whether these practitioners adopt the tenets of minimally invasive dentistry in their clinical practice.

DISCUSSION

Scientific evidence shows that minimal intervention is a viable alternative for treatment of dental caries in public health settings. In this minimally invasive treatment modality, only those dentin tissues infected by the cariogenic pathogens that cause disease progression are removed; deeper affected dentin, which is amenable to remineralization, is preserved^5,7-9. To ensure maximum prevention of healthy tissue loss, carious lesions must be diagnosed in the early stages of enamel and dentin involvement, when procedures can still be adopted to arrest caries progression and achieve clinical control. At more advanced stages, minimally invasive procedures can be performed⁶.

From this perspective, the present study sought to investigate the approaches adopted by Family Health Strategy dentists at a large city in Northeast Brazil for management of dental caries in primary molars, at different stages and levels of disease activity. The objective was to ascertain whether these practitioners adopt the tenets of minimally invasive dentistry in their clinical practice.

The first case vignette presented described a case of chronic caries with minimal tooth structure loss, restricted to inner portion of enamel, with no periapical lesions and no pain, in a patient with good dietary and oral hygiene habits. In this scenario, as in a previous study¹³, most respondents reported they would choose a preventive approach, with particular emphasis on topical fluoride treatment. Such management is considered appropriate for the presented case.

Nevertheless, more than 15% of respondents would have performed invasive procedures, especially complete caries removal. These procedures cause major loss of healthy tissue and should be replaced by approaches designed to conserve tooth structure, whereby incipient enamel and dentin lesions are not removed, but instead are treated to arrest and control caries progression. At more advanced stages, minimally invasive procedures that preserve tooth structure can still be used, alongside educational and health promotion interventions, with a view to treating the disease of dental caries rather than simply restoring carious lesions^9,14.

Stepwise excavation (removal of carious tissue in two stages) and, more recently, single-visit partial caries removal are alternative management strategies that can be used to control dental caries in cases of deep dentin involvement, due to the potential for remineralization and cure of the dentin-pulp complex^4,7,15-18. Within this context, the second vignette presented to respondents consisted of a case of active caries affecting the inner dentin layer, with substantial tooth structure loss, in a patient with sugar sensitivity, a carbohydrate-rich diet, and deficient oral hygiene. As in a previous report¹⁷, respondents predominantly chose invasive procedures for this case, especially complete caries removal. However, the gold-standard treatment for such a case would be partial caries removal. Currently, there is no evidence to justify complete caries removal even in cases of infected dentin; partial removal is always preferable, as complete removal entails a risk of pulp exposure^9,18-19.

The last vignette presented was a case of active dental caries, restricted to the outer dentin layer, in a patient with no tooth sensitivity, a satisfactory diet, and good oral hygiene. In this case, most respondents reported they would adopt curative procedures, particularly complete caries removal; again, this would constitute inappropriate management. From a public health standpoint, pit-and-fissure sealants provide a noninvasive alternative for control of some of the etiologic agents of dental caries, by acting as a mechanical barrier between the pathogenic biofilm and the tooth structure²⁰. Systematic reviews of the literature support this method as a preventive and therapeutic alternative to arrest the development of carious lesions^21-24. The purpose of sealing dental caries is to control the disease. Thus, it would be the treatment of choice for the case vignette presented, as it enables maximal preservation of tooth structure while arresting the decay process, by limiting the substrate needed for bacterial growth in the remaining dentin.

Another aspect assessed in the present study was the agreement between respondents' choices and the tenets of minimally invasive dentistry, which is considered the gold standard of therapy. By cross-referencing the responses of all 33 participants against the gold standard, we obtained a mean kappa value of 0.44, which denotes moderate agreement¹². Divergences in management approaches between professionals have been commonly reported in the literature^1,10, and probably occur because diagnosis of dental caries is still a point of substantial disagreement among dentists²⁵. The multiple treatment protocols taught at different dental schools may also explain the differences in procedures adopted by the participants of this study.

Except in the first case vignette, respondents predominantly chose invasive approaches in situations where conservation of tooth structure was recommended. A similar trend has been reported in other studies of the same topic, but in the permanent dentition^1,10. This finding demonstrates that respondents' practices are outdated when it comes to minimally invasive procedures, and reveals a need for continuing education among primary health care professionals. Targeted efforts at establishing more flexible work hours, or even provision of financial incentives by the State, are potential alternatives for the achievement of this goal.

One limitation of our study was the absence of information on respondents' approaches to management of active enamel caries. We suggest that further studies be conducted to investigate this scenario, as minimally invasive approaches are the cornerstone of prevention and control of the carious process in primary teeth in these cases. In addition, the small number of studies designed to evaluate dentists' practices for management of caries in primary teeth prevented comparison of our results to those of other authors. Another limitation was the fact that not all participants could be interviewed. Although limited by its cross-sectional design, this study provides the opportunity for a critical look at the approaches adopted by primary health care practitioners within the framework of the Brazilian Unified Health System. As these professionals are responsible for the care of a representative portion of the Brazilian population, our findings should prompt reflection on the possibility of overtreatment, and, consequently, unnecessary resource consumption-a highly relevant issue in public health.

CONCLUSION

Most respondents chose invasive interventions for the majority of case vignettes involving primary teeth, even in situations in which preservation of tooth structure was recommended. Agreement across professionals was moderate, which suggests wide variability in treatment choices.