# Deep caries and pulp exposures management preferences in permanent teeth: A survey amongst Spanish dentists

Laura Bailleul, Laura Ceballos, Sophie Doméjean, Victoria Fuentes

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Laura Bailleul, Laura Ceballos, Sophie Doméjean, Victoria Fuentes. Deep caries and pulp exposures management preferences in permanent teeth: A survey amongst Spanish dentists. International Endodontic Journal, 2024, 58 (2), pp.239-256. 10.1111/iej.14159. hal-04930057

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# Deep caries and pulp exposures management preferences in permanent teeth: A survey amongst Spanish dentists

Laura Bailleul<fnref n="1" /> ID

Laura Ceballos<fnref n="1" /> ID

Sophie Doméjean<fnref n="2" /> ID

Victoria Fuentes<fnref n="1" /> ID

## Correspondence

Laura Ceballos, Area of Stomatology, Health Sciences Faculty, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain.
Email: laura.ceballos@urjc.es

## Abstract

**Aim:** To assess Spanish dentists' management preferences for deep caries removal and exposed pulps in permanent teeth.

**Methodology:** A web-based open and anonymous survey was distributed by social media and a specific website for this project amongst dentists practicing in Spain. The questionnaire comprised 40 questions, divided into five sections: (1) demographic data and professional activity; (2) carious tissue removal; (3) decision-making regarding pulp exposure; (4) direct pulp capping and (5) pulpotomy procedures in permanent teeth. Results were descriptively analysed. Logistic regression (95% CI) analyses and X<fnref n="2" /> tests were carried out.

**Results:** A total of 538 responses were received. Half the respondents (53.7%) preferred to perform complete caries excavation for shallow and moderate carious dentin lesions, and selective excavation to firm dentin for deep lesions (57.8%). Selective removal to soft dentin and stepwise removal were much less indicated (15.4% and 10.9%, respectively). Exposed pulps in asymptomatic teeth were treated by direct pulp capping (over 80%), decreasing in the presence of reversible pulpitis symptoms (57.1%). If irreversible pulpitis was diagnosed, a pulpectomy would be performed by 53.5% and 89.9% of the respondents in, respectively, immature and mature teeth. Pulpotomy was performed routinely only by 26.4% of the clinicians. Patients' attitudes and priorities were the most relevant criteria when performing direct pulp capping and pulpotomy, together with the history of pain and the presence of bleeding. Regarding the clinical procedure, dry cotton was preferred to obtain haemostasis and Biodentine was the material of election.

**Conclusions:** Caries removal preferences and management of pulp exposure by dentists practicing in Spain deviated from vital pulp treatment guidelines, mainly regarding indications and case selection. Pulp exposure was managed by direct pulp capping in asymptomatic cases, whilst immature permanent molars favoured the indication of pulpotomy when pulpitis was diagnosed. Most clinicians used hydraulic calcium silicate cement, specifically Biodentine, to perform vital pulp treatments. Postgraduate formation and continuing education in caries lesions management and vital pulp treatments were consistently related to more conservative and updated decisions.

## KEYWORDS

permanent teeth, pulp exposure, pulpotomy, survey, vital pulp therapy

<footnote n="1">¹Faculty of Health Sciences, IDIBO Research Group, Universidad Rey Juan Carlos, Madrid, Spain</footnote>

<footnote n="2">²Clermont Auvergne University, Clermont-Ferrand, France</footnote>

<footnote>This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Author(s). *International Endodontic Journal* published by John Wiley & Sons Ltd on behalf of British Endodontic Society.</footnote>
INTRODUCTION

The better knowledge and understanding of pulpal de-
fence mechanisms, as well as the improvement in bio-
active materials, have led to the development of a panel
of strategies aiming to preserve tooth structure and pulp
vitality as much as possible, especially in the case of deep
caries lesions (DCL) with or without pulp exposure, which
is part of what is known as vital pulp treatments (VPTs).
Therefore, VPTs not only include pulp capping and partial
and full pulpotomies when the pulp is exposed to caries,
trauma or mechanically but also those techniques to man-
age deep caries avoiding its exposure, such as selective
caries removal, indirect pulp capping and stepwise exca-
vation (Duncan et al., 2019).

Vital pulp treatments offer relevant advantages, as
pulp preservation allows to maintain its physiological
and defensive functions (Taha & Al-khatib, 2022; Wolters
et al., 2017), tooth stiffness is hardly altered because less
tooth tissue is removed (González-López et al., 2006) and
post-operative pain incidence and intensity related to these
procedures decrease (Galani et al., 2017). In addition,
VPT procedures are less technique-sensitive and more
cost-effective (Bjørndal et al., 2019; Brodén et al., 2019; Li
et al., 2019).

However, the VPT application represents a paradigm
shift for many clinicians who are reluctant to implement
it despite recent studies supporting its clinical success
(Asgary et al., 2015, 2024; Cushley et al., 2021; Eggmann
et al., 2022). VPTs require a careful case selection with a
meticulous assessment of pulp symptomatology, to revise
the classic criteria used for case selection for some treat-
ments and, also, to imply more scrupulous clinical proce-
dures (Duncan et al., 2019).

DCLs, with a progression no deeper than the pul-
pal quarter with a zone of dentin separating the le-
sions from the pulp chamber in teeth with reversible
pulpitis, are recommended to be treated with selective
carious-tissue removal techniques (Duncan et al., 2019;
Schwendicke et al., 2016). Therefore, a less invasive ex-
cavation procedure, leaving firm or soft dentin on the
cavity floor, is advised to avoid pulp exposure. However,
most dentists still prefer to perform a complete removal
of the decayed tissue (Alnahwi et al., 2018; Crespo-
Gallardo et al., 2018; Crespo-Gallardo et al., 2018; Croft
et al., 2022; Delikan et al., 2021; Edwards et al., 2021a;
Koopaeei et al., 2017; Oen et al., 2007; Schwendicke
et al., 2013; Schwendicke & Göstemeyer, 2016;
Stangvaltaite et al., 2013; Weber et al., 2011), something
that nowadays is considered as overtreatment and no
longer advocated (Schwendicke et al., 2016), due to
higher risk of pulp exposure and lower success (Barros
et al., 2020; Schwendicke et al., 2021).

If pulp exposure cannot be adverted due to extreme
DCLs or because nonselective carious tissue removal
techniques are conducted, direct pulp capping and par-
tial and complete pulpotomy constitute a conservative
alternative to pulpectomy with similar success rates
(Galani et al., 2017). Hence, pulpotomy is no longer
restricted to pulp exposures due to trauma or caries in
immature permanent teeth and can be even consid-
ered a definitive treatment for mature teeth diagnosed
with ‘irreversible’ pulpitis (Alqaderi et al., 2016; Lin
et al., 2020).

The excellent clinical outcomes in recent reports of these minimally invasive treatments that preserve pulp vitality are associated with an enhanced protocol that includes the use of absolute field isolation with a rubber dam, magnification and disinfection of the pulp wound. Regarding the restorative procedure, the application of hydraulic calcium silicate cements over the exposed pulp, and the definitive restoration of the tooth in the same session, ensuring adequate marginal sealing, have also been considered of relevance (Asgary et al., 2024; Duncan et al., 2019). However, the importance of other clinical factors remains controversial as old principles are changing regarding the patient's age, degree of root development, pulp bleeding, bleeding time and the type and concentration of the disinfectant solution to be applied over the pulp tissue (Asgary et al., 2024).

The absence of agreement amongst clinicians con-
cerning their preferences to manage DCLs and pulp expo-
sures has been previously assessed (Careddu et al., 2021;
Chai et al., 2020; Hatipoğlu, 2018; Hatipoğlu et al., 2023;
Patel et al., 2022; Schwendicke et al., 2017; Stangvaltaite
et al., 2017; Stangvaltaite-Mouhat et al., 2023). However,
in the last years, consensus, position statements, clinical
studies, systematic reviews and meta-analyses focused
on VPTs have been published aiming to improve the
decision-making of dentists and the standardization of
clinical protocols (AAE, 2021; Duncan et al., 2019; Innes
et al., 2016; Schwendicke et al., 2016). Hence, to eval-
uate if this growing scientific evidence has been trans-
lated into clinical practice seems to be essential, as well
as detecting those drawbacks or misunderstandings that
should be improved in future guidelines. In Spain, two
studies have been published mainly dedicated to DCL
management and not specifically focused on decision-
making and the details of the clinical protocol when
pulp is exposed during caries excavation (Crespo-
Gallardo et al., 2018; Crespo-Gallardo et al., 2018).

Therefore, the main objective was to assess Spanish
dentists' management preferences for deep caries removal
and exposed pulps in permanent teeth. The secondary ob-
jectives were to evaluate: (1) carious tissue removal pref-
erences according to their demographic and professional
characteristics; (2) the association of root development status and pulpal symptoms on their decision-making when the pulp is exposed in permanent teeth; (3) the patient's related and clinical factors considered relevant for VPT outcomes, concretely in direct pulp capping and pulpotomy and (4) to analyse if the indication for VPTs, the clinical procedure and the materials of choice were adapted to the current recommendations.

## METHODS

This online questionnaire-based study was approved by the Institutional Review Board (#0212202023920).

An electronic questionnaire was designed taking into consideration the consensus and position statements regarding management of DCLs and pulp exposures by International Caries Consensus Collaboration (ICCC), European Society of Endodontology (ESE) and American Association of Endodontists (AAE), as well as the CHERRIES checklist for reporting results of internet e-surveys (Eysenbach, 2004) and STROBE checklist for cross-sectional studies (von Elm et al., 2007). Using the online survey service Microsoft Forms (Microsoft Office 365®), a draft version was developed and answered by 35 dentists who were asked to give judgmental feedback, mainly regarding the time to be completed and the clarity of the questions. After minor adjustments, the final version of the questionnaire was approved to be run online.

### Questionnaire

The questionnaire comprised 40 questions that were divided into five sections: (1) demographic data and professional activity; (2) carious tissue removal; (3) decision-making regarding pulp exposure; (4) direct pulp capping procedure in permanent teeth and (5) pulpotomy procedure in permanent teeth.

### Demographic data and professional activity

The following information was collected: age, gender, university and year of graduation, postgraduate training, continuing education in operative caries management and VPT and area of expertise.

### Carious tissue removal preferences

Five questions aimed to describe the caries removal threshold and the preferred clinical protocol in terms of

instruments for this procedure and rubber dam isolation placement.

### Decision-making regarding pulp exposure

Decision-making regarding pulp exposure was explored through two clinical situations. Two periapical radiographs showing a permanent molar with extreme DCL were presented, one in a 7-year-old child with open apices, and the other in a 40-year-old patient. For both cases, it was mentioned that pulp exposure could not be avoided during caries tissue excavation and both patients were healthy and compliant. Three clinical scenarios for each molar were described according to pulpal symptomatology: vital and asymptomatic, reversible pulpitis and irreversible pulpitis; for each clinical scenario, the following treatments could be chosen: direct pulp capping, partial pulpotomy, total pulpotomy or pulpectomy.

### Direct pulp capping in permanent teeth

Participants were asked about their indications of direct pulp capping for permanent teeth in children and adolescents, with or without open apices, and in adults. Also, the influence of factors related to the patient and the clinical situation on decision-making was asked using a Likert scale.

The suggested factors related to the patient were age, oral and general health status and attitude and priorities. Those related to clinical findings were previous pain, pulp exposure size, bleeding, colour of the blood, time to reach haemostasis, rubber dam isolation, cavity margins in enamel and root development status. Finally, the respondents had to indicate the solutions preferred to achieve haemostasis, as well as the capping material to place over the pulp.

### Pulpotomy in permanent teeth

Participants had to answer the same questions previously formulated for the direct pulp capping procedure to which three more were added regarding the frequency in their clinical practice of pulpotomies (partial and total), and finally, the reasons to execute this treatment.

### Questionnaire administration

A link containing the survey was distributed through social media, Instagram, Facebook and Whatsapp, without
targeting any specific group and using the authors' per-
sonal accounts. Moreover, a specific website was created
for this project, and the Spanish Society of Periodontics
(SEPA), dental councils from Asturias, Pontevedra and
Ourense, Bizkaia, Gipuzkoa, Albacete, Córdoba, Tenerife,
Las Palmas and Ceuta and the Fundación Clínica
Universitaria of the Universidad Rey Juan Carlos helped
to spread the survey sending an email to their members.
The final version of the survey provided cover information
describing the objectives, the researchers and University
conducting the study and the time required to completion
(approximately 15 min), and it was also reassured that
all the individual data collected were compliant with the
data protection and confidentiality guidelines. Moreover,
informed consent was obtained from all participants.

The online self-administrated survey was accessible
and available for 25 days, between the 2nd and the 27th
of June 2021.

Power analysis

With 39764 registered dentists in Spain in 2021, 50% of the respondents were expected to perform operative treatment of caries lesions with a 95% confidence interval of ±5% desired precision. A nonresponse rate of 20% was considered and added for a final sample size estimated. Therefore, a minimum number of 457 respondents was required.

Statistical analysis

At the beginning of the survey, participants were asked if
they carried out operative treatments of caries lesions in
their daily practice, being an exclusion criterium a nega-
tive answer, and consequently, the questionnaire ended
at that point. In the following sections, they also had to
affirm that they performed direct pulp cappings and pul-
potomies, before answering the questions related to these
VPTs.

It was not possible to leave unanswered questions;
nevertheless, a ‘Don’t know/ Don’t Answer’ item was in-
cluded in each question according to the CHERRIES cri-
teria (Eysenbach, 2004), to ensure the completeness rate.
These responses constituted <1% of the answers and were
not considered in the statistical analysis.

A descriptive analysis was carried out. Chi-square tests
were used to determine the relationship between respon-
dent characteristics and carious tissue removal prefer-
ences. A binary logistic regression model was performed
to assess the relationship between respondent character-
istics and clinical decisions regarding pulp exposure (VPT

vs. pulpectomy), and direct pulp capping and pulpotomy
in permanent teeth.

The level of statistical significance was set at α=0.05 and the analysis was performed using the Stata 16 program (StataCorp, College Station, TX, USA).

RESULTS

Demographic data and professional activity

This survey was answered by 620 individuals; 82 respond-
ents were excluded from the analysis as some were not den-
tists (n=12) and others did not give their consent (n=9)
or declared not to perform any operative treatments of
caries lesions in their daily clinical activity (n=61); thus,
the final sample consisted in 538 respondents (Figure 1).

They all answered the questions regarding carious tis-
sue removal preferences and decision-making regarding
pulp exposure. The respondents were aged between 23
and 70 years old and were mostly females (64.3%). They
graduated in 20 different Spanish dental schools although
most of them studied in universities located in Madrid.
Most participants (55.0%) were enrolled in a postgradu-
ate course or had completed some type of postgraduate
training. With respect to work experience, those who had
5 years of experience or less predominated (35.0%), fol-
lowed by those with more than 15 years of experience in
dentistry (34.8%). Most of the respondents (57.1%) indi-
cated that they worked in other people's private clinics,
and 35.7% and 29.5% declared that their professional ac-
tivity was focused, respectively, on general dentistry or
prosthodontics and on conservative dentistry. More than
70% of the respondents received continuing education/
training in operative management of caries lesions and
VPTs (73.2%).

Carious tissue removal preferences

Table 1 presents the results related to the respondent's carious tissue removal preferences. Most respondents (53.7%) indicated that, for shallow and moderate caries lesions, they preferred to perform a complete caries removal procedure (yellow and hard dentin, 'cri dentinaire'). For DCLs, 57.8% of the respondents indicated that they would reach firm dentin, leaving altered tissue in colour or texture (no soft) at the bottom of the cavity. Moreover, the choice to perform a complete caries removal decreased from 53.7% to 16.0% with respect to the previous assumption. However, only 15.4% of the participants would select to leave soft dentin on the cavitary floor to avoid pulp exposure or to perform a stepwise caries removal (10.9%).
<figure><img src="image_2.png" /><figcaption>FIGURE 1 Flowchart (n (%)).</figcaption></figure>

The preference for caries removal threshold and technique for shallow or moderate, and DCLs was not influenced either by gender or clinical experience. In contrast, younger dentists opted for more conservative one-session options to manage DCLs, such as selective caries removal to firm and soft dentin (p = .03). Also, postgraduate education (for shallow and moderate lesions), continuing education in caries management and VPTs, as well as professional expertise significantly favoured a more conservative removal regardless of caries depth (p = .004).

The preferred instruments for carious excavation were hand excavators and round burs in low-speed rotary instruments in the same percentage (65.5%), followed by round burs in high-speed handpieces (59.2%). Only 15.6% of the respondents always changed the instruments to sterile ones when pulp exposure occurred.

Regarding the placement of rubber dam in DCL management, 35.5% of the respondents declared to use it always, whilst almost 25% admitted never using it. The statistical analysis showed that postgraduate formation, continuing education on VPT and the area of expertise were relevant variables that influenced rubber dam use (p ≤ .001).

## Pulp exposure management

Regardless of the root development status, in a vital pulp and in the absence of symptoms, clinicians considered

direct pulp capping as the treatment of choice after pulp exposure during caries removal (81.54% and 82.5%, respectively for the immature and the mature molar; Table 2). For a diagnosis of reversible pulpitis, a similar and lower proportion of respondents performed a direct pulp capping (approximately 57% for both cases). On the contrary, the percentage of partial pulpotomy increased to 27.8% for the immature molar and to 27.7% for pulpectomy in the mature molar (Table 2).

Finally, for pulp exposure with irreversible pulpitis symptoms, pulpectomy was the most selected option for both the immature (53.5%) and the mature permanent molar (89.9%). Nevertheless, 44% of the participants would still choose to perform a pulpotomy, partial (16.9%) or total (27.1%), in the immature molar (Table 2).

These decisions were not affected either by the respondent's gender or by their clinical experience and their postgraduate education (p > .05). Age was shown to be related to the decision for the mature molar without any pulpal symptomatology (p = .005). Respondents older than 60 years and those aged between 30 and 39 years were more likely to prefer pulpectomy over VPT than those aged 20–29 years, respectively (Table 3).

In the case of the immature molar, the continuing education toward VPT modified the process of decision regardless of the pulpal status, favouring its indication over pulpectomy (Table 3). And, finally, the area of expertise was related to the decisions for teeth with irreversible pulpitis, regardless of root formation status, as general
<table><caption>TABLE 1 Carious tissue removal preferences by Spanish dentists (n (%)).</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Total n (%)</th><th colspan="3">Shallow or moderate carious lesion</th><th colspan="3">Deep carious lesion</th><th rowspan="2">Chi-square test p-value</th></tr><tr><th>Hard dentin</th><th>Firm dentin</th><th>Soft dentin</th><th>Chi-square test p-value</th><th>Hard dentin</th><th>Firm dentin</th><th>Soft dentin</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Male</td><td>190 (35.6)</td><td>108 (56.8)</td><td>79 (41.6)</td><td>3 (1.6)</td><td>&gt;.05</td><td>35 (18.4)</td><td>115 (60.5)</td><td>23 (12.1)</td><td>17 (9.0)</td><td>&gt;.05</td></tr><tr><td>Female</td><td>343 (64.4)</td><td>178 (51.9)</td><td>158 (46.1)</td><td>7 (2)</td><td></td><td>50 (14.6)</td><td>193 (56.3)</td><td>59 (17.2)</td><td>41 (12.0)</td><td></td></tr><tr><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>20-29</td><td>171 (32.1)</td><td>94 (55)</td><td>76 (44.4)</td><td>1 (0.6)</td><td>&gt;.05</td><td>27 (15.8)</td><td>93 (54.4)</td><td>31 (18.1)</td><td>20 (11.7)</td><td>.03</td></tr><tr><td>30-39</td><td>167 (31.4)</td><td>89 (53.3)</td><td>74 (44.3)</td><td>4 (2.4)</td><td></td><td>19 (11.4)</td><td>107 (64.1)</td><td>32 (19.2)</td><td>9 (5.4)</td><td></td></tr><tr><td>40-49</td><td>120 (22.6)</td><td>63 (52.5)</td><td>55 (45.8)</td><td>2 (1.7)</td><td></td><td>22 (18.3)</td><td>70 (58.3)</td><td>11 (9.2)</td><td>17 (14.2)</td><td></td></tr><tr><td>50-59</td><td>33 (6.2)</td><td>20 (60.6)</td><td>12 (36.4)</td><td>1 (3)</td><td></td><td>6 (18.2)</td><td>20 (60.6)</td><td>3 (9.1)</td><td>4 (12.1)</td><td></td></tr><tr><td>≥60</td><td>41 (7.7)</td><td>19 (46.3)</td><td>20 (48.8)</td><td>2 (4.9)</td><td></td><td>10 (24.4)</td><td>18 (49.3)</td><td>5 (12.2)</td><td>8 (10.9)</td><td></td></tr><tr><td>532 (100)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Clinical experience since graduation</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0-5</td><td>185 (34.9)</td><td>105 (56.8)</td><td>79 (42.7)</td><td>1 (0.5)</td><td>&gt;.05</td><td>31 (16.8)</td><td>99 (53.5)</td><td>35 (18.9)</td><td>20 (10.8)</td><td>&gt;.05</td></tr><tr><td>6-10</td><td>103 (19.4)</td><td>57 (55.3)</td><td>43 (41.8)</td><td>3 (2.9)</td><td></td><td>12 (11.7)</td><td>69 (67)</td><td>17 (16.5)</td><td>5 (4.9)</td><td></td></tr><tr><td>11-15</td><td>58 (10.9)</td><td>29 (50.0)</td><td>28 (48.3)</td><td>1 (1.7)</td><td></td><td>7 (12.1)</td><td>33 (56.9)</td><td>10 (17.2)</td><td>8 (13.8)</td><td></td></tr><tr><td>≥15</td><td>184 (34.7)</td><td>94 (51.1)</td><td>85 (46.2)</td><td>5 (2.7)</td><td></td><td>35 (19.0)</td><td>105 (57.1)</td><td>19 (10.3)</td><td>25 (13.6)</td><td></td></tr><tr><td>Qualification</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>DDS</td><td>155 (29.1)</td><td>102 (65.8)</td><td>52 (33.6)</td><td>1 (0.7)</td><td>&lt;.001</td><td>27 (17.4)</td><td>96 (61.9)</td><td>14 (9.0)</td><td>18 (11.6)</td><td>&gt;.05</td></tr><tr><td>MSc/PD</td><td>295 (55.3)</td><td>154 (52.2)</td><td>137 (46.4)</td><td>4 (1.4)</td><td></td><td>47 (15.9)</td><td>170 (57.6)</td><td>50 (17.0)</td><td>28 (9.5)</td><td></td></tr><tr><td>PhD</td><td>83 (15.6)</td><td>30 (36.1)</td><td>48 (57.8)</td><td>5 (6.0)</td><td></td><td>11 (13.3)</td><td>42 (50.6)</td><td>18 (21.7)</td><td>12 (14.5)</td><td></td></tr><tr><td>533 (100.0)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Continuing education in carious lesions operative treatment and VPT since graduation</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>143 (26.8)</td><td>92 (64.3)</td><td>51 (35.7)</td><td>-</td><td>.004</td><td>27 (18.9)</td><td>94 (65.7)</td><td>10 (7.0)</td><td>12 (8.4)</td><td>.004</td></tr><tr><td>Yes</td><td>390 (73.2)</td><td>194 (49.7)</td><td>186 (47.7)</td><td>10 (2.6)</td><td></td><td>58 (14.9)</td><td>214 (54.9)</td><td>72 (18.5)</td><td>46 (11.8)</td><td></td></tr><tr><td>533 (100.0)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><caption>TABLE 1 (Continued)</caption><thead><tr><th rowspan="2">Area of expertise</th><th rowspan="2">Total n (%)</th><th colspan="4">Shallow or moderate carious lesion</th><th colspan="4">Deep carious lesion</th></tr><tr><th>Hard dentin</th><th>Firm dentin</th><th>Soft dentin</th><th>Chi-square test p-value</th><th>Hard dentin</th><th>Firm dentin</th><th>Soft dentin</th><th>Step wise removal</th><th>Chi-square test p-value</th></tr></thead><tbody><tr><td>Conserv.</td><td>159 (29.8)</td><td>72 (45.3)</td><td>84 (52.8)</td><td>3 (1.9)</td><td>.003</td><td>15 (9.4)</td><td>94 (59.1)</td><td>31 (19.5)</td><td>19 (12.0)</td><td>.009</td></tr><tr><td>Endod.</td><td>87 (16.3)</td><td>38 (43.7)</td><td>45 (51.7)</td><td>4 (4.6)</td><td></td><td>14 (16.1)</td><td>46 (52.9)</td><td>20 (23.0)</td><td>7 (8.1)</td><td></td></tr><tr><td>General/ Prosth.</td><td>190 (35.6)</td><td>123 (64.7)</td><td>65 (34.2)</td><td>2 (1.1)</td><td></td><td>37 (19.5)</td><td>109 (57.4)</td><td>22 (11.6)</td><td>22 (11.6)</td><td></td></tr><tr><td>Paediatric</td><td>35 (6.6)</td><td>14 (40.0)</td><td>20 (57.1)</td><td>1 (2.9)</td><td></td><td>3 (8.6)</td><td>22 (62.9)</td><td>8 (22.9)</td><td>2 (5.7)</td><td></td></tr><tr><td>Ortho.</td><td>14 (2.6)</td><td>7 (50.0)</td><td>7 (50.0)</td><td>-</td><td></td><td>2 (14.3)</td><td>10 (71.4)</td><td>-</td><td>2 (14.3)</td><td></td></tr><tr><td>Perio/Impl.</td><td>48 (9.0)</td><td>32 (66.7)</td><td>16 (33.3)</td><td>-</td><td></td><td>14 (29.2)</td><td>27 (56.3)</td><td>1 (2.1)</td><td>6 (12.5)</td><td></td></tr><tr><td></td><td>533 (100.0)</td><td>286 (53.7)</td><td>237 (44.5)</td><td>10 (1.9)</td><td></td><td>85 (16.0)</td><td>308 (57.8)</td><td>82 (15.4)</td><td>58 (10.9)</td><td></td></tr></tbody></table>

Note: Don't Know/Don't Answer responses were not considered for the statistical analysis since the representation was <1%. Not all respondents answered all the questions.

Abbreviations: Conserv., conservative dentistry; DDS, Doctor in Dental Surgery (Degree); Endod., endodontics; General/Prosth., general dentistry and prosthodontics; MSc/PD, Master of Science or Postgraduate Degree; Ortho., orthodontics; Paediatric, paediatric dentistry; Perio/Impl., periodontics and implantology; PhD, Philosophiae Doctor; VPT, vital pulp treatment.

dentists and prosthodontists significantly preferred to perform pulpectomy more than practitioners working in the field of conservative dentistry (Table 3).

## Direct pulp capping

Most participants (79.5%) indicated performing direct pulp cappings in their daily clinical activity (Figure 1); moreover, the results showed that 72.4% executed this treatment in both immature and mature permanent teeth.

Regarding respondent's characteristics, neither age nor their clinical experience were factors related to the decision to carry out this treatment. In contrast, male dentists were 0.61 times less prone to perform direct pulp cappings than females. Practitioners with a master's degree and a PhD degree performed more direct pulp cappings than those with only a graduate degree (Table 4).

Patients' characteristics considered as the most important when deciding whether to perform a direct pulp capping were, sorted in descending order: patient's attitude (4.4), priorities (4.1), oral health status (4), age (3.9) and finally, their general state of health (3.8; Figure 2).

The clinical criteria rated with the highest values according to relevance were, with a similar mean value (4.6), the history of previous pain and the presence of bleeding at the time of exposure followed by the size of the pulp exposure (4.5). The time of haemostasis was also considered 'very important' (4.4) whilst the criterium rated as less relevant was 'cavitary margins in enamel' (3.8; Figure 2).

The preferred method to achieve haemostasis was pressure with a dry cotton (43.7%), followed by the application of a cotton impregnated in a solution of 0.2–2% chlorhexidine or 0.5–5% sodium hypochlorite (19.5% and 19.0%, respectively). The preferred material to place in contact with the exposed pulp tissue was Biodentine (Septodont®; 45%), followed by calcium hydroxide (19.7%) and MTA® (19.4%; Table 5).

## Pulpotomy

Only 26.4% of the respondents reported that pulpotomy on mature permanent teeth is part of their practice in cases of irreversible pulpitis or pulp exposure (Table 4). Nevertheless, pulpotomy was considered routine and exceptional by, respectively, 35.9% and 55.6% of them.

The pulpotomy decision was not related to the gender, age, or clinical experience of the respondents. Nevertheless, postgraduate, and continuing education as well as the area of expertise were shown to be significantly related to it (Table 4). Respondents with a Master's, a PhD degree or with a continuing education in VPT were more
<table><caption>**TABLE 2** Treatment choice (n (%) depending on symptoms and root development status.</caption><thead><tr><th rowspan="2">Symptoms</th><th rowspan="2">Treatment</th><th colspan="2">Root development status</th></tr><tr><th>Open apex</th><th>Closed apex</th></tr></thead><tbody><tr><td rowspan="4">Vital and asymptomatic</td><td>DPC</td><td>414 (81.5)</td><td>419 (82.5)</td></tr><tr><td>PP</td><td>55 (10.8)</td><td>10 (1.9)</td></tr><tr><td>FP</td><td>18 (3.5)</td><td>3 (0.6)</td></tr><tr><td>PULPEC</td><td>21 (4.1)</td><td>76 (15.0)</td></tr><tr><td rowspan="4">Reversible pulpitis</td><td>DPC</td><td>290 (57.1)</td><td>296 (58.3)</td></tr><tr><td>PP</td><td>141 (27.8)</td><td>55 (10.8)</td></tr><tr><td>FP</td><td>52 (10.2)</td><td>16 (3.1)</td></tr><tr><td>PULPEC</td><td>25 (4.9)</td><td>141 (27.7)</td></tr><tr><td rowspan="4">Irreversible pulpitis</td><td>DPC</td><td>12 (2.3)</td><td>4 (0.8)</td></tr><tr><td>PP</td><td>86 (16.9)</td><td>24 (4.7)</td></tr><tr><td>FP</td><td>138 (27.1)</td><td>23 (4.5)</td></tr><tr><td>PULPEC</td><td>272 (53.5)</td><td>457 (89.9)</td></tr><tr><td colspan="2">Total</td><td>508 (100)</td><td>508 (100)</td></tr></tbody></table>

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>

Note: Don't Know/Don't Answer responses were not considered for the statistical analysis since the representation was <2%. Not all respondents answered all the questions.

Abbreviations: DPC, direct pulp capping; FP, full pulpotomy; PP, partial pulpotomy; PULPEC, pulpectomy.

likely to perform pulpotomies than the others. Regarding the area of expertise, endodontists and paediatric dentists performed pulpotomies 2.5 and 3.6 times more than those that execute conservative dentistry, respectively.

The patients' factors taken into account by the respondents were the attitude of the patient (4.4), the patient's priorities (4.2) and age (4.1). Regarding the clinical factors affecting pulpotomy treatment, the presence of bleeding and the time to achieve haemostasis were considered to be very important (4.5), followed by the history of previous pain (4.4), pulp exposure size, rubber dam isolation and colour of the bleeding (4.3; Figure 2).

The preferred method to control haemostasis was pressure with dry cotton (40.0%), closely followed by the application of cotton soaked with sodium hypochlorite (32.1%). And the preferred material to cover the exposed pulp was Biodentine (56.0%), followed by MTA (23.4%) and calcium hydroxide (9.9%; Table 5).

The main motivations argued by the respondents to perform pulpotomies were dual: 'it is a scientifically endorsed procedure' (90.0%) and 'it is a less invasive procedure that preserves pulp vitality' (66.0%).

Finally, 41.9% of the participants who did not perform pulpotomy indicated that they were not aware that it was

an accepted treatment in case of irreversible pulpitis or pulp exposure. The others affirmed that they were aware of the indications of pulpotomy, and the reasons argued not to perform pulpotomies were the possibility of exacerbation of pain and consequent problems with patients (32.8%) followed by not trusting in its success (21.7%), lack of acceptance of treatment by patients (15.4%) and because they have not received training in this regard (13.9%), amongst others.

## DISCUSSION

The present study evaluated the preferences of dentists practicing in Spain regarding the management of DCLs and, specifically, pulpal exposures, using an online questionnaire survey that was answered by 538 respondents.

According to the data reported by the General Dental Council of Spain (Consejo General de dentistas, 2023), the sample seems to be a quite accurate reflection of the Spanish demographic reality of dentistry with some clarifications. In the present study, the percentage of female dentists was higher (64.3%) than reported by the Dental Council (58.4%), this slight difference can be attributed to
<table><caption>**TABLE 3** Bivariate logistic regression model showing significant predictors (participant's profile), odds ratio (OR; 95% confidence interval) for treatment decision-making (n (%)) regarding pulp exposure (preference of PULPEC over VPT in asymptomatic teeth, and reversible pulpitis, or preference of VPT over PULPEC in irreversible pulpitis).</caption><thead><tr><th rowspan="2">Root development</th><th rowspan="2">Symptoms</th><th rowspan="2">Factor</th><th colspan="3">Treatment decision</th></tr><tr><th>VPT<sup>a</sup></th><th>PULPEC<sup>b</sup></th><th>OR (95%CI)</th></tr></thead><tbody><tr><td rowspan="6">Immature permanent molar</td><td rowspan="2">No symptoms</td><td>Continuing education in carious lesions operative treatment and VPT since graduation</td><td></td><td></td><td></td></tr><tr><td>No</td><td>117 (89.3)</td><td>14 (10.7)</td><td>6.325 (2.493-16.043)***</td></tr><tr><td>Yes</td><td>370 (98.1)</td><td>7 (1.9)</td><td>1</td></tr><tr><td rowspan="2">Reversible pulpitis</td><td>Continuing education in carious lesions operative treatment and VPT since graduation</td><td></td><td></td><td></td></tr><tr><td>No</td><td>117 (89.3)</td><td>14 (10.7)</td><td>3.981 (1.759-9.009)***</td></tr><tr><td>Yes</td><td>366 (97.1)</td><td>11 (2.9)</td><td>1</td></tr><tr><td rowspan="2">Irreversible pulpitis</td><td>Continuing education in carious lesions operative treatment and VPT since graduation</td><td></td><td></td><td></td></tr><tr><td>No</td><td>48 (20.3)</td><td>83 (30.5)</td><td>0.581 (0.386-0.874)**</td></tr><tr><td>Yes</td><td>188 (79.7)</td><td>189 (69.5)</td><td>1</td></tr><tr><td rowspan="10">Mature permanent molar</td><td rowspan="2">No symptoms</td><td>Area of expertise</td><td></td><td></td><td></td></tr><tr><td>Conserv.</td><td>78 (33.1)</td><td>76 (27.9)</td><td>1</td></tr><tr><td rowspan="5">Irreversible pulpitis</td><td>Endod.</td><td>53 (22.5)</td><td>33 (12.1)</td><td>1.564 (0.914-2.678)</td></tr><tr><td>General/Prosth.</td><td>66 (28.0)</td><td>109 (40.1)</td><td>0.590 (0.380-0.916)*</td></tr><tr><td>Paediatric</td><td>16 (6.8)</td><td>18 (6.6)</td><td>0.866 (0.412-1.822)</td></tr><tr><td>Ortho.</td><td>7 (3.0)</td><td>6 (2.2)</td><td>1.137 (0.365-3.538)</td></tr><tr><td>Perio/Impl.</td><td>16 (6.8)</td><td>30 (11.0)</td><td>0.520 (0.262-1.030)</td></tr><tr><td rowspan="5">Irreversible pulpitis</td><td>Age</td><td></td><td></td><td></td></tr><tr><td>20-29</td><td>149 (89.8)</td><td>17 (10.2)</td><td>1</td></tr><tr><td>30-39</td><td>125 (80.1)</td><td>31 (19.9)</td><td>2.174 (1.149-4.111)*</td></tr><tr><td>40-49</td><td>104 (90.4)</td><td>11 (9.6)</td><td>0.927 (0.417-2.060)</td></tr><tr><td>50-59</td><td>26 (83.9)</td><td>5 (16.1)</td><td>1.686 (0.572-4.967)</td></tr><tr><td>≥60</td><td>28 (70.0)</td><td>12 (30.0)</td><td>3.756 (1.613-8.719)**</td></tr><tr><td rowspan="6">Irreversible pulpitis</td><td>Area of expertise</td><td></td><td></td><td></td></tr><tr><td>Conserv.</td><td>22 (43.1)</td><td>132 (28.9)</td><td>1</td></tr><tr><td>Endod.</td><td>14 (27.5)</td><td>72 (15.8)</td><td>1.167 (0.563-2.419)</td></tr><tr><td>General/Prosth.</td><td>11 (21.6)</td><td>164 (35.9)</td><td>0.402 (0.188-0.860)*</td></tr><tr><td>Paediatric</td><td>2 (3.9)</td><td>32 (7.0)</td><td>0.375 (0.083-1.678)</td></tr><tr><td>Ortho.</td><td>-</td><td>13 (2.8)</td><td>-</td></tr><tr><td></td><td>Perio/Impl.</td><td>2 (3.9)</td><td>44 (9.6)</td><td>0.272 (0.062-1.207)</td></tr></tbody></table>

Note: Don't Know/Don't Answer responses were not considered for the statistical analysis since the representation was <2%. Not all respondents answered all the questions.

Abbreviations: Conserv., conservative dentistry; Endod., endodontics; General/Prosth., general dentistry and prosthodontics; Ortho., orthodontics; Paediatric, paediatric dentistry; Perio/Impl., periodontics and implantology; PULPEC, pulpectomy; VPT, vital pulp treatment.

<sup>a</sup>VPT is the reference variable in teeth without symptoms and reversible pulpitis.

<sup>b</sup>PULPEC is the reference variable for irreversible pulpitis.

*p-value ≤ .05. **p-value ≤ .01. ***p-value ≤ .001.

the fact that the profession is becoming more feminized over the years and our survey was answered preferentially by younger dentists in whom the percentage of women is higher. As for age, a precise comparison cannot be made,

since the age ranges of the dentists surveyed do not coincide with those of the Council's register. However, the highest percentages correspond to dentists under 50 years of age, as is the case in our survey. Furthermore, the Community
<table><caption>TABLE 4 Distribution of treatment choice for direct pulp capping and pulpotomy according to demographic factors (n (%)).</caption><thead><tr><th rowspan="3">Factor</th><th colspan="3">Treatment choice</th><th colspan="3">Pulpotomy</th></tr><tr><th colspan="3">Direct pulp capping</th><th colspan="3">Pulpotomy</th></tr><tr><th>No</th><th>Yes<sup>a</sup></th><th>OR (95%CI)</th><th>No</th><th>Yes<sup>b</sup></th><th>OR (95%CI)</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>54 (54.6)</td><td>283 (66.1)</td><td>1</td><td>246 (64.6)</td><td>89 (63.1)</td><td></td></tr><tr><td>Male</td><td>45 (45.5)</td><td>145 (33.9)</td><td>0.615 (0.395-0.958)*</td><td>135 (35.4)</td><td>52 (36.9)</td><td></td></tr><tr><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>20-29</td><td>36 (36.4)</td><td>136 (31.8)</td><td></td><td>126 (33.1)</td><td>44 (31.2)</td><td></td></tr><tr><td>30-39</td><td>26 (26.3)</td><td>138 (32.2)</td><td></td><td>115 (30.2)</td><td>46 (32.6)</td><td></td></tr><tr><td>40-49</td><td>21 (21.2)</td><td>97 (22.7)</td><td></td><td>84 (22.1)</td><td>33 (23.4)</td><td></td></tr><tr><td>50-59</td><td>7 (7.1)</td><td>26 (6.1)</td><td></td><td>26 (6.8)</td><td>7 (5.0)</td><td></td></tr><tr><td>≥60</td><td>9 (9.1)</td><td>31 (7.2)</td><td></td><td>30 (7.9)</td><td>11 (7.8)</td><td></td></tr><tr><td>Clinical experience since graduation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0-5</td><td>37 (37.4)</td><td>149 (34.8)</td><td></td><td>135 (35.4)</td><td>49 (34.8)</td><td></td></tr><tr><td>6-10</td><td>20 (20.2)</td><td>83 (19.4)</td><td></td><td>71 (18.6)</td><td>31 (22.0)</td><td></td></tr><tr><td>11-15</td><td>5 (5.1)</td><td>51 (11.9)</td><td></td><td>38 (10.0)</td><td>16 (11.4)</td><td></td></tr><tr><td>≥15</td><td>37 (37.4)</td><td>145 (33.9)</td><td></td><td>137 (36.0)</td><td>45 (31.9)</td><td></td></tr><tr><td>Qualification</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>DDS</td><td>40 (40.4)</td><td>116 (27.1)</td><td>1</td><td>128 (33.6)</td><td>26 (18.4)</td><td>1</td></tr><tr><td>MSc/PD</td><td>50 (50.5)</td><td>241 (56.3)</td><td>1.662 (1.038-2.662)*</td><td>198 (52.0)</td><td>89 (63.1)</td><td>2.213<br>(1.355-3.613)***</td></tr><tr><td>PhD</td><td>9 (9.1)</td><td>71 (16.6)</td><td>2.720 (1.246-5.941)*</td><td>55 (14.4)</td><td>26 (18.4)</td><td>2.327<br>(1.241-4.364)**</td></tr><tr><td>Continuing education in carious lesions operative treatment and VPT since graduation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>42 (42.4)</td><td>100 (23.4)</td><td>0.414 (0.262-0.654)***</td><td>116 (30.5)</td><td>23 (16.3)</td><td>0.445<br>(0.271-0.732)***</td></tr><tr><td>Yes</td><td>56 (57.6)</td><td>328 (76.6)</td><td>1</td><td>265 (69.6)</td><td>118 (83.7)</td><td>1</td></tr><tr><td>Area of expertise</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Conserv.</td><td>24 (24.2)</td><td>135 (31.5)</td><td>1</td><td>115 (30.2)</td><td>42 (29.8)</td><td>1</td></tr><tr><td>Endod.</td><td>17 (17.2)</td><td>69 (16.1)</td><td>0.726 (0.363-1.432)</td><td>45 (11.8)</td><td>41 (29.1)</td><td>2.495<br>(1.437-4.330)***</td></tr><tr><td>General/Prosth.</td><td>38 (38.4)</td><td>148 (34.6)</td><td>0.692 (0.395-1.214)</td><td>161 (42.3)</td><td>25 (17.7)</td><td>0.425<br>(0.245-0.737)**</td></tr><tr><td>Paediatric</td><td>1 (1.0)</td><td>34 (7.9)</td><td>6.044 (0.790-46.273)</td><td>15 (3.9)</td><td>20 (14.2)</td><td>3.651<br>(1.712-7.783)***</td></tr><tr><td>Ortho.</td><td>3 (3.0)</td><td>12 (2.8)</td><td>0.711 (0.187-2.709)</td><td>11 (2.9)</td><td>2 (1.4)</td><td>0.498 (0.106-2.340)</td></tr><tr><td>Perio/Impl.</td><td>16 (16.2)</td><td>30 (7.0)</td><td>0.333 (0.158-0.703)**</td><td>34 (8.9)</td><td>11 (7.8)</td><td>0.886 (0.412-1.906)</td></tr><tr><td>Total</td><td>99 (18.4)</td><td>428 (79.6)</td><td></td><td>381 (70.8)</td><td>142 (26.4)</td><td></td></tr></tbody></table>

Abbreviations: CI, confidence interval; Conserv., conservative dentistry; DDS, Doctor in Dental Surgery (Degree); Endod., endodontics, General/Prosth., general dentistry and prosthodontics; MSc/PD, Master of Science or Postgraduate Degree; OR, odds ratio; Ortho., orthodontics; Paediatric, paediatric dentistry; Perio/Impl., periodontics and implantology; PhD, Philosophiae Doctor; VPT, vital pulp treatment.

of Madrid is the region in which the density of dentists is the highest, with a very marked difference with respect to the rest of the communities. Accordingly, we also

obtained the highest percentage of responses from professionals practicing in Madrid, although the responses were geographically distributed throughout the country unlike

<footnote><sup>a</sup>Performing direct pulp capping is the reference variable ('Yes').</footnote>

<footnote><sup>b</sup>Performing pulpotomy is the reference variable ('Yes').</footnote>

<footnote>*p-value ≤ .05. **p-value ≤ .01. ***p-value ≤ .001.</footnote>
## PATIENT CHARACTERISTICS

<figure><img src="image_5.png" /></figure>

## CLINICAL CRITERIA

<figure><img src="image_6.png" /><figcaption>**FIGURE 2** Importance that participants assigned to patient characteristics and clinical criteria when performing direct pulp cappings and pulpotomies. Results are scored between 1 and 5 being 1 ‘not important’ and 5 ‘extremely important’. DK/DA, don’t know/don’t answer.</figcaption></figure>

previous studies conducted in Spain (Crespo-Gallardo et al., 2018; Crespo-Gallardo et al., 2018). Finally, it should be pointed out that it very common in Spain for dentists to undertake postgraduate training of a professional nature after completing their undergraduate studies.

In the present survey, the recommendation to perform a selective caries removal to firm dentin for shallow and moderate dentin carious lesions that require an operative treatment (Innes et al., 2016; Schwendicke et al., 2016) seems not to be completely accepted by Spanish dentists,

as a nonselective caries removal technique was still chosen by most of the clinicians (53.7%). In contrast, a more conservative approach was chosen when there was a risk of pulp exposure, with 57.8% of the respondents opting for a selective removal to reach firm dentin and a dramatically decreased percentage of clinicians that would perform a complete caries removal (16.0%). These results suggest a shift in the attitudes of dentists in Spain in comparison with a previous report in which total caries excavation was the preferred treatment option for more than 80% of
<table><caption>**TABLE 5** Materials of choice to perform haemostasis and to place over the pulp tissue in direct pulp capping and pulpotomy procedures (n (%)).</caption><thead><tr><th></th><th>Direct pulp capping</th><th>Pulpotomy</th></tr></thead><tbody><tr><td><strong>Haemostatic agent</strong></td><td></td><td></td></tr><tr><td>Clorhexidine (0.2–2%)</td><td>83 (19.5)</td><td>20 (14.3)</td></tr><tr><td>Sodium hypochlorite (0.5–5.25%)</td><td>81 (19.0)</td><td>45 (32.1)</td></tr><tr><td>Saline solution</td><td>31 (7.3)</td><td>7 (5.0)</td></tr><tr><td>Haemostatic agent (pherric sulphate and aluminium chloride)</td><td>29 (6.8)</td><td>6 (4.3)</td></tr><tr><td>Anaesthesia</td><td>8 (1.9)</td><td>2 (1.4)</td></tr><tr><td>Dry cotton ball (pressure)</td><td>186 (43.7)</td><td>56 (40.0)</td></tr><tr><td>Others</td><td>8 (1.9)</td><td>4 (2.9)</td></tr><tr><td><strong>Pulp capping material</strong></td><td></td><td></td></tr><tr><td>MTA®</td><td>83 (19.4)</td><td>33 (23.4)</td></tr><tr><td>Biodentine®</td><td>192 (45.0)</td><td>79 (56.0)</td></tr><tr><td>Theracal®</td><td>29 (6.8)</td><td>3 (2.1)</td></tr><tr><td>Conventional GIC</td><td>17 (4.0)</td><td>3 (2.1)</td></tr><tr><td>Resin reinforced GIC</td><td>19 (4.4)</td><td>6 (4.3)</td></tr><tr><td>Calcium hydroxide</td><td>84 (19.7)</td><td>14 (9.9)</td></tr><tr><td>None</td><td>2 (0.5)</td><td>2 (1.4)</td></tr><tr><td>Others</td><td>1 (0.2)</td><td>1 (0.7)</td></tr><tr><td>Total</td><td>428 (100)</td><td>142 (100)</td></tr></tbody></table>

dentists in the case of DCLs (Crespo-Gallardo et al., 2018), and in comparison with reports from other countries (Croft et al., 2019; Edwards et al., 2021a; Oen et al., 2007; Stangvaltaite et al., 2017; Weber et al., 2011). Nevertheless, the data obtained in surveys should be analysed with caution since in a clinical situation dentists seem to adopt a less conservative management of DCLs (Croft et al., 2022) than in a surveyed theory (Croft et al., 2019).

Spanish dentists seem to have not assumed yet that leaving soft carious dentin under permanent perfectly sealed restorations avoids pulp exposure allowing reparative pulp-dentine complex reactions to take place, as selective caries removal to soft dentin and stepwise caries removal strategies were only selected by 15.4% and 10.9% of the clinicians, respectively. The comparison of these results with survey-based studies carried out in other countries is not straightforward mainly due to differences in the clinical situations suggested, the use of terms such as ‘partial removal’ or ‘selective removal’ without indicating the hardness of the dentin left on the cavity floor (Chai et al., 2020; Chisini et al., 2015), and because pulp symptoms (Alnahwi et al., 2018; Croft et al., 2019; Stangvaltaite et al., 2013) and status of root development (Seale & Glickman, 2008) were considered criteria to define the

removal technique, unlike current recommendations (Duncan et al., 2019; Innes et al., 2016).

Regarding the relationship between demographic factors and preferred removal technique for carious lesions, the influence of the age of the dentists was only relevant for DCLs (Croft et al., 2019; Schwendicke et al., 2013). According with previous reports, gender (Alnahwi et al., 2018; Chai et al., 2020; Croft et al., 2019; Edwards et al., 2021a; Oen et al., 2007; Schwendicke et al., 2013) and years since graduation (Alnahwi et al., 2018; Chai et al., 2020; Croft et al., 2019; Oen et al., 2007) did not modify the removal technique preference. However, the postgraduate qualification, the dental specialty they dedicated most, and the continuing education in operative caries management and VPT were significantly related to a more conservative approach to carious dentin removal procedures. Accordingly, Koopaeei et al. (2017) reported that caries excavation performed by general dentists and endodontists was more invasive than by paediatric dentists. However, no relevance has been found for continuing education in other surveys (Croft et al., 2019), nor for postgraduate education (Edwards et al., 2021a).

## Pulp exposure

The pulpal status played a significant role in the clinical management of the proposed cases, as a direct relationship was observed between the severity of the pulpitis and the invasiveness of the treatments that respondents would perform as a first option, in accordance with previous reports (Crespo-Gallardo et al., 2018; Croft et al., 2019; Edwards et al., 2021b; Kakudate et al., 2019; Koopaeei et al., 2017; Stangvaltaite et al., 2013), even if the preoperative radiography provided was the same.

Most of the practitioners (over 80%) chose to perform a direct pulp capping in asymptomatic cases in which pulp exposure could not be avoided during caries removal, regardless of the root formation status, being aligned with published guidelines (Duncan et al., 2019). These percentages are similar to those reported in surveys conducted in other countries for general practitioners (Croft et al., 2019; Edwards et al., 2021b; Koopaeei et al., 2017; Schwendicke et al., 2013; Stangvaltaite et al., 2017; Stangvaltaite-Mouhat et al., 2023); or previously in Spain (79.2%; Crespo-Gallardo et al., 2018). In contrast, when endodontists in the United States faced a similar situation, direct pulp capping was the preferred treatment in a much lower percentage (58%; Koopaeei et al., 2017), as well as by members of the Irish Endodontic Society and of the Academia Italiana de Endodonzia for a young patient (53.0%) or an adult (43.5%; Careddu et al., 2021).
Although the results seem to indicate that Spanish dentists are more inclined to less invasive treatments, 15.0% of the respondents still recommended pulpectomy in asymptomatic mature teeth. This aggressive attitude may have been influenced by the limited clinical success attributed to direct pulp capping of exposed pulps during caries excavation until a few years ago, being recommended especially in cases of traumatic pulp exposure or immature teeth (Löst, 2006).

For pulp exposures in teeth with reversible pulpitis the recommended procedure by ESE and AAE is direct pulp capping (AAE, 2021; Duncan et al., 2019), based on the high long-term clinical success determined in recent reports, even in carious pulp exposures or in mature teeth (Marques et al., 2015; Matsuo et al., 1996; Ricucci et al., 2023), being also more cost-effective than root canal treatment (Brodén et al., 2019).

Accordingly, direct pulp capping was still the most frequent treatment selected by the practitioners for immature and mature teeth with DCLs and reversible pulpitis (57.1% and 58.3%, respectively), although the percentages were much lower than those for asymptomatic cases. As a consequence, dentists that selected more aggressive treatments, namely partial pulpotomy for immature teeth (27.8%) and pulpectomy for mature (27.7%) increased, departing from the position statements. This trend was also observed in other surveys (Croft et al., 2022; Kakudate et al., 2019; Koopaeei et al., 2017; Stangvaltaite et al., 2013), in which the mere presence of symptoms, regardless of their severity, led clinicians to perform endodontic treatment in percentages reaching 90% (Crespo-Gallardo et al., 2018; Koopaeei et al., 2017; Stangvaltaite et al., 2013).

Also, the extent of root formation changed the attitude of the respondents, as in immature teeth with reversible pulpitis, VTPs, direct pulp capping and pulpotomies, were preferred. It can be assumed that these less radical options were selected to allow complete root formation, and because the possibility of endodontic treatment remains in case of failure. It should be noted that 38.0% of the dentists decided to perform a partial or total pulpotomy. This decision may have been driven by the fact that direct pulp capping should be performed after a complete caries removal and this procedure commonly leads to an increase in the size of the pulp exposure. Moreover, a significant bacterial contamination of the pulp in extreme DCLs has been reported (Demant et al., 2021). Recently, partial and complete pulpotomies have been proposed as an alternative to this clinical situation, with a clinical success similar to direct pulp capping or even higher (Lin et al., 2020; Wolters et al., 2017).

Regarding teeth with DCLs and symptoms compatible with irreversible pulpitis, VPT, specifically, pulpotomy,

has been recently proposed instead of pulpectomy even when apices are completely formed (Asgary et al., 2024; Duncan et al., 2019; Taha & Khazali, 2017). The reason for this innovative approach is sustained in the healing potential of the pulp, as the inflammation and necrotic areas are usually confined to the area adjacent to the carious site (Demant et al., 2021). According to our results, the treatment of preference was influenced by the root development status and patient age, as 89.9% of the respondents indicated pulpectomy for mature teeth, whilst 44.0% would preserve pulp vitality by performing a pulpotomy for immature teeth.

Therefore, dentists still consider that the success of the VPT decreases in adult patients and closed apices, according to previous reports (Croft et al., 2019; Scalzilli et al., 2022; Stangvaltaite-Mouhat et al., 2023), and VPTs are accepted but still restricted to children or young permanent teeth as a definitive solution.

The decision-making for pulp exposures in DCLs seems not to be supported by the scientific evidence and several actions should be considered such as the abandonment of the dichotomic classification between reversible and irreversible pulpitis, the definition of clear and consensual guidelines by the main scientific societies and the effective communication to dental students and general dental practitioners, not only specialists in endodontics, as most of the clinical cases should not need to be referred.

## Direct pulp capping and pulpotomies in permanent teeth

Consistent with previous surveys, pulpotomy was a less popular VTP in comparison with direct pulp capping (Crespo-Gallardo et al., 2018; Crespo-Gallardo et al., 2018; Schwendicke et al., 2017; Stangvaltaite et al., 2017), as it was performed by a smaller number of dentists (n = 142), and half of them (55.6%) admitted that they do it in an 'exceptional' way in their daily routine, which agrees with other published studies (Chin et al., 2016; Edwards et al., 2021b).

Although female dentists were more prone to perform direct pulp cappings, no influence of gender was detected for pulpotomy. However, both VTPs were influenced by postgraduate education, continuing education in VTP, as well as the area of expertise. Pulpotomies were preferentially performed by endodontists and paediatric dentists in comparison with dentists that are dedicated to conservative dentistry, probably because it is an operative treatment that they are used to execute in case of pulp exposure due to caries or trauma.

Regarding the characteristics of the patients that the clinicians considered 'extremely important' when
performing direct pulp cappings and pulpotomies, the patient's attitudes and priorities stood out. This may be a sign that dentists do not consider these techniques as definitive treatments with the same success rate as conventional pulpectomy, so they would reserve them for those patients who wish to preserve pulp vitality and whose attitude towards newer treatments is more favourable. This is also related to the reasons they argue for not performing pulpotomies, such as thinking that there may be an exacerbation of pain, lack of confidence in its success, not an accepted technique or fear that it will not be accepted by patients.

Age was also considered an extremely important factor for a high percentage of dentists, especially for pulpotomies, in agreement with previous surveys (Careddu et al., 2021; Scalzilli et al., 2022). However, the importance of age as a prognostic factor for VTP outcomes has been questioned in recent reports (Asgary et al., 2024; Crespo-Gallardo, et al., 2018; Crespo-Gallardo et al., 2018; Duncan et al., 2023; Eggmann et al., 2022; Mejåre et al., 2012; Taha & Al-khatib, 2022; Tzanetakis et al., 2023) and, accordingly, is not considered a limiting factor for ESE nor AAE (AAE, 2021; Duncan et al., 2019).

Focusing on the clinical factors that respondents considered the most relevant, as could be expected, the size of the pulp exposure was one of the highest rated for direct pulp capping, and not so much for pulpotomy. The extent of the pulp exposure is a criterium that determines the VTP to be performed (Yurdagüven et al., 2023).

Another important factor for direct pulp capping and pulpotomy was the presence of bleeding as it has been considered a sign of pulp vitality although its relevance is not so clear (Duncan, 2022). Also, the history of previous pain was considered very important for both treatments by a high number of respondents, which is logical for direct pulp capping, as this VTP is only reversed for asymptomatic cases or those in which the pulp is reversibly inflamed (Duncan et al., 2019). According to the decision-making results, the presence of more severe symptoms would lead to a more aggressive treatment, such as endodontic treatment instead of pulpotomy. It should be highlighted that, although cases of irreversible pulpitis can be successfully treated with partial pulpotomy, the severity of the symptoms and signs may influence the prognostic (Careddu et al., 2021) and different stages of pulpitis should be taken into consideration (Wolters et al., 2017) for a more precise treatment plan.

The time to achieve haemostasis was also highly rated as it has been considered a limitation in performing these treatments. In fact, during the direct pulp capping procedure, it is recommended to perform pulpotomy when haemostasis is not obtained after 5 min (Duncan et al., 2019),

and to perform root canal treatment when haemostasis cannot be achieved during pulpotomy after 5 min (Duncan et al., 2019) or even 10 min (AAE, 2021). Nevertheless, recent clinical reports call into question its relevance for VPT outcomes (Asgary et al., 2024; Careddu et al., 2021; Taha & Al-khatib, 2022). Therefore, new protocols including longer bleeding times could be accepted in the future, as the correlation between pulp inflammation and bleeding seems not to be so straight (Taha & Al-khatib, 2022; Tan et al., 2020).

Interestingly, clinicians chose the presence of margins in enamel as a relevant factor in a lower percentage in comparison with other clinical factors, although adequate coronal sealing has been considered crucial for long-term success (Asgary et al., 2024; Taha & Al-khatib, 2022). In contrast, rubber dam isolation was frequently rated as 'extremely important', in agreement with ESE recommendations, although its impact on clinical outcomes has not been proved (Asgary et al., 2024).

The preferred method to achieve haemostasis for direct pulp capping and pulpotomy was pressure with dry cotton, in agreement with the management described for UK primary care dentists (Edwards et al., 2021b). However, antimicrobial lavage of the pulp exposure with sodium hypochlorite (0.5-5%) or chlorhexidine (0.2-2%), before placing a hydraulic calcium silicate cement has been recommended by ESE (Duncan et al., 2019, 2023). Specifically, the application of sodium hypochlorite has been proposed to positively influence clinical outcomes (Asgary et al., 2024; Duncan, 2022; Taha & Al-khatib, 2022). Therefore, Spanish dentists are not updated regarding disinfection of the pulp wound, probably due to the thought that sodium hypochlorite may cause an irreversible injury to the pulp tissue, without paying attention to the benefit of the chemical elimination of the infectious challenge.

In the present study, nearly half of the respondents used a hydraulic calcium silicate, such as Biodentine, to cover the pulp exposure during direct pulp capping procedures, followed by calcium hydroxide and MTA in a similar percentage. Therefore, Spanish dentists are aligned with ESE recommendations (Bjøndal et al., 2019; Duncan et al., 2019), and conspicuously prefer Biodentine to MTA, in contrast with surveys performed in other countries (Croft et al., 2019; Delikan et al., 2021; Edwards et al., 2021b). Regarding pulpotomy, around 80% of the dentists indicated using hydraulic calcium silicate cement, and again, Biodentine was the most popular. The lower setting time of Biodentine and the limited tooth staining in comparison with MTA may have been the reasons for this choice, as both materials have demonstrated a high clinical success (Asgary et al., 2022; Cushley et al., 2019).

Nevertheless, although most of the respondents opted for a calcium silicate cement, a high percentage of
clinicians still resort to calcium hydroxide, the classical material of choice for these clinical situations and with a much lower cost and easier, simpler application and lower clinical success (Ather et al., 2022; Cushley et al., 2021). However, it should be noted that in comparison with previous reports in Spain (Crespo-Gallardo et al., 2018; Crespo-Gallardo et al., 2018) or in other countries (Chisini et al., 2015; Croft et al., 2019; Edwards et al., 2021b), the percentage of dentists that reported to use calcium hydroxide was significantly lower in our study, and in agreement with a survey fulfilled in other countries by endodontists (Careddu et al., 2021).

Finally, it should be mentioned that the information obtained in the present study was based on the answers to an online distributed questionnaire survey. This design is considered a valid method to describe professional practices and preferences, although a causal relationship between variables cannot be established. Another limitation is that, as it was electronically administrated, this may induce a risk of participation bias by selecting young respondents. In addition, the University Ethics Committee urged the use of Microsoft Forms - Microsoft Office 365, which limited the fulfilment of some of the CHERRIES requirements (Eysenbach, 2004), such as duplicated answers, fraudulent information or erroneous deliberated answers. Moreover, it was not possible to determine the response rate, since the number of dentists reached by the survey is not known.

## CONCLUSIONS

The obtained results suggest that only a low percentage of clinicians perform selective caries removal to soft dentin or stepwise caries removal in DCLs, even with a high risk of pulp exposure. If pulp is exposed during caries removal, the absence of pulp symptoms as well as the immature root status favour VPT indication. In both clinical situations, the decisions were not in line with the recommendations in recent guidelines and consensus statements. The attitude and priorities of the patient are the criteria that dentists consider more relevant when performing direct pulp capping and pulpotomy, as well as previous history of pain and the presence of bleeding. The pulp exposure size and the time required to achieve haemostasis were also highly rated for direct pulp capping and pulpotomy, respectively. Most of the clinicians used hydraulic calcium silicates to perform VPTs, whilst haemostasis was achieved using a dry cotton pellet. Finally, postgraduate formation as well as continued training in operative management of carious lesions and VPT were consistently related to more conservative and updated decisions.

## AUTHOR CONTRIBUTIONS

Laura Bailleul: Methodology, writing – original draft, writing – review and editing. Laura Ceballos: Conceptualization, methodology, writing – original draft, writing – review, editing and supervision. Sophie Doméjean: Writing – review and supervision of the project. Victoria Fuentes: Methodology, resources, formal analysis, data curation, writing – review, supervision and editing.

## ACKNOWLEDGEMENTS

The authors would like to thank the following societies, professional Spanish councils and other institutions for their cooperation and help in distributing the questionnaire: Spanish Society of Periodontics, colleges from; Asturias, Pontevedra y Ourense, Bizkaia, Gipuzkoa, Albacete, Córdoba, Tenerife, Las Palmas and Ceuta and the Fundación Clínica Universitaria de la Universidad Rey Juan Carlos. This paper is part of a thesis to be submitted in partial fulfillment of the requirements for a doctoral degree of the student of the International Doctoral School of Universidad Rey Juan Carlos, Laura Bailleul.

## FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

## CONFLICT OF INTEREST STATEMENT

There is no conflict of interest.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

## ETHICS STATEMENT

This online questionnaire-based study was approved by the Institutional Review Board (#0212202023920) and informed consent was obtained from all participants.

## ORCID

Laura Bailleul https://orcid.org/0009-0003-7505-5743

Laura Ceballos https://orcid.org/0000-0002-6024-9559

Sophie Doméjean https://orcid.org/0000-0002-4792-1777

Victoria Fuentes https://orcid.org/0000-0001-6568-4157

## REFERENCES

AAE. (2021) AAE position statement on vital pulp therapy. *Journal of Endodontics*, 47(9), 1340-1344. Available from: https://doi.org/10.1016/j.joen.2021.07.015
Alnahwi, T.H., Alhamad, M., Majeed, A. & Nazir, M.A. (2018) Management preferences of deep caries in permanent teeth among dentists in Saudi Arabia. *European Journal of Dentistry*, 11(4), 192-195. Available from: https://doi.org/10.4103/ejd.ejd

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**How to cite this article:** Bailleul, L., Ceballos, L., Doméjean, S. & Fuentes, V. (2025) Deep caries and pulp exposures management preferences in permanent teeth: A survey amongst Spanish dentists. *International Endodontic Journal*, 58, 239–256. Available from: https://doi.org/10.1111/iej.14159