Influence of academic training and professional experience on the management of deep caries lesions

Ci a ion: A oyo-Bo e, S.; Ribas-Pe ez, D.; Bennasa Ve ges, C.; Rod iguez Menacho, D.; Villal a He nandez-F anch, P.; Ba be o Na a o, I.; Cas año Séique , A. In luence o Academic T aining and P o essional Expe ience on he Managemen o Deep Ca ies Lesions. Heal hca e 2024,12, 1907. h ps:// doi.o g/10.3390/heal hca e12191907 Academic Edi o s: Sil ia Ca uso, Vincenzo D’An òand S e ano Ma ina Recei ed: 7 Augus 2024 Re ised: 9 Sep embe 2024 Accep ed: 12 Sep embe 2024 Published: 24 Sep embe 2024 Copy igh : © 2024 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). heal hca e A icle In luence o Academic T aining and P o essional Expe ience on he Managemen o Deep Ca ies Lesions Sebas iana A oyo-Bo e 1, Da id Ribas-Pe ez 2,* , Ca alina Bennasa Ve ges 1, Diego Rod iguez Menacho 2, Paloma Villal a He nandez-F anch 2, Ignacio Ba be o Na a o 2and An onio Cas año Séique 2 1Uni e si y o he Balea ic Islands, 07006 Palma de Mallo ca, Spain; s.a [email p o ec ed] (S.A.-B.); [email p o ec ed] (C.B.V.) 2Depa men o S oma ology, Uni e si y o Se ille, 41001 Se ille, Spain; [email p o ec ed] (D.R.M.); [email p o ec ed] (I.B.N.); [email p o ec ed] (A.C.S.) *Co espondence: [email p o ec ed] Abs ac : Backg ound/Objec i es: Managing ca ies lesions ha a ec he inne hi d o he den in is c ucial o ensu ing pulp i ali y; he clinician mus make decisions ha will a ec he i ali y o he oo h. Ou pu pose is o unde s and he beha io o Spanish den is s in ea ing deep ca i ies and o examine whe he a ia ions exis based on hei academic aining and/o yea s o p o essional expe ience. Me hods: This s udy was app o ed by he e hics commi ee o he Balea ic Islands CEI-IB. A su ey was conduc ed using he Su eyMonkey pla o m wi h 11 ques ions, he i s 4 o which ocused on de ining he cha ac e is ics o he esponden s. The ollowing six conce ned a clinical case o deep ca ies in oo h numbe 4.7, and he las ega ded he opinion o he ac ual ea men o he case. The su ey was sen by email in Ap il 2022. The esul s we e analyzed wi h he SPSS 29.0 p og am using he chi-squa e es . Resul s: A o al o 347 esponses we e ob ained (93.95%), and hose su eyed s a ed ha hey apply minimal in e en ion concep s in hei ea men s, wi h 90.49% pe o ming conse a i e den is y ea men s daily. A o al o 56.48% o he esponden s had bachelo ’s deg ees, 12.39% had g adua ed, 33.14% had a pos g adua e deg ee, 38.90% had a mas e ’s deg ee, and 17% had a doc o a e. Mos (40.63%) had been in p o essional p ac ice o 16–30 yea s. Conclusions: Signi ican di e ences we e iden i ied ega ding yea s o p o essional expe ience in e ms o decision-making in me hods o ea men and he choice o ma e ials used o pulp p o ec ion. Likewise, signi ican di e ences we e ound ega ding he academic aining o he esponden s, he ca i y cleaning me hod selec ed, and he use o chemical subs ances o emo ing ca ious den in. We can conclude ha academic aining and yea s o p o essional p ac ice in luence decision-making a some poin s in ea ing deep ca ies lesions. Keywo ds: ca ies lesions; pulp i ali y; den is beha io ; academic aining; conse a i e den is y 1. In oduc ion Managing ca ies and ca ious lesions ep esen s a daily challenge o he clinician in making p e en i e and es o a i e decisions. A icles ha e been published o help clinicians e alua e he isk o ca ies and make decisions ega ding a comp ehensi e ea men plan o he disease and es o a i e ea men s o ca ious lesions [1–4]. Ca ies begins wi h he demine aliza ion o he enamel and p og esses inside he oo h un il i eaches he den al pulp. The den in–pulp complex ac i a es he de ensi e p ocesses o he oo h h ough in e nal ubula calci ica ion and he o ma ion o neoden in. The ela ionship be ween he agg essi eness o ca ies and he e ec i eness o he oo h’s de enses will gi e ise o di e en clinical si ua ions ega ding he ac i i y o ca i ies, becoming inac i e in some si ua ions. Classically, he clinical a i ude ocused on he ope a i e es o a ion o lesions, ega d- less o he deg ee o ca ies ac i i y, e en in lesions ha a ec only he enamel and ex e nal Heal hca e 2024,12, 1907. h ps://doi.o g/10.3390/heal hca e12191907 h ps://www.mdpi.com/jou nal/heal hca e Heal hca e 2024,12, 1907 2 o 12 hi d o he den in. These ope a ional es o a ion c i e ia ha e a ied based on minimal in e en ion den is y and scien i ic e idence [ 5 ]. I is impo an o es ablish he le el o in ol emen o he den al issues due o ca ies and es ablish he pa ien ’s isk o ca ies so he mos app op ia e and comp ehensi e ea men o he disease can be indica ed, a oiding ope a i e ea men s ha en ail signi ican des uc ion o he den al issues and o e ing he pa ien he possibili y o p o ec ion and de ense agains he p og ession o ca ies. Howe e , s udies ocused on de e mining he conse a i e a i ude o minimal in- e en ion o in e en ionis app oaches, in ela ion o yea s o p o essional expe ience and aining in ca iology, show con adic o y esul s [ 6 ]. In a s udy conduc ed in London wi h 217 gene al den is s, a mo e in e en ionis a i ude was demons a ed in mo e expe ienced den is s; howe e , less-expe ienced den is s pe o med less conse a i e ca i ies, which can be explained om di e en poin s o iew bu which highligh s he lack o judgmen in he managemen o ca ious lesions [6]. Deep ca ious lesions in he inne hi d o he den in, e y close o he pulp, a e a signi ican isk o exposing he pulp when he ca ious den in is emo ed. In such scena - ios, con empo a y p inciples o minimal in e en ion ad oca e o he a ge ed emo al o ca ies and he applica ion o bioac i e ma e ials ha acili a e he emine aliza ion o demine alized den in. This app oach enables a highly conse a i e emo al o damaged issues, ex ac ing only he disin eg a ed den in while p ese ing he demine alized, hus p e en ing pulp exposu e. This ea men con as s sha ply wi h adi ional cleaning me h- ods, which ecommended comple ely emo ing all demine alized den in un il eaching ha d den in, he eby inc easing he isk o pulp exposu e. As we ha e p e iously s a ed, he e is a lack o uni o mi y in he way o ac ing in hese inju ies. On he o he hand, new biologically ac i e ma e ials ha e been in oduced in ecen yea s and ha e been changing he modus ope andi o den is s. Mine al T ioxide Agg ega e (MTA) was de eloped by Loma Linda Uni e si y (Loma Linda, CA, USA) and was comme cialized in 1998 (P oRoo MTA, Den sply, Yo k, PA, USA). I consis s o icalcium and dicalcium silica e pa icles, e acalcium e ic alumina e, calcium sul a e dihyd a e, icalcium oxide, silica e oxide, and bismu h ioxide. In he se ing p ocess, MTA ini ially p esen s a pH o 10.2 ha ises o 12.5 wi hin he i s hou s [ 3 ]. MTA is indica ed o endodon ic ea men and pulp p o ec ion in ea ing ee h wi h pulp exposu e by di ec coa ing o o o al o pa ial pulpo omy [ 4 ]. Bioden ine is a calcium silica e-based bioma e ial. I s composi ion includes icalcium silica e, zi conium oxide, calcium oxide, calcium ca bona e, i on oxide pigmen in he powde , and calcium chlo ide and polyca boxyla e in he aqueous solu ion. Bioden ine is used in conse a i e den is y ea men s in pulp capping (di ec and indi ec ), pulpo omy, endodon ic d illing, and apexi ica ion, among o he s [4]. This s udy aims o analyze how Spanish den is s ace his ea men , co ela ing hei a i ude o age and p o essional aining. 2. Ma e ials and Me hods This esea ch was app o ed by he e hics commi ee o he Balea ic Islands CEI-IB in a session held on Ma ch 30 (no. 04/2022), CEI Code: IB 4142/20 PI. A alida ed su ey was conduc ed using he Su eyMonkey pla o m o 13 ques ions based on a clinical case (Figu e 1A,B) o a ca ies lesion ha had been ea ed wi h selec- i e ca ies emo al, applica ion o bioac i e ma e ial (Sep odon , Sain -Mau -des-Fossés, F ance, Bioden ine), and illed wi h bulK ill composi e and uni e sal adhesi e wi h he selec i e enamel e ch echnique (Figu e 1A,B). A g oup o p o esso s om Se ille Uni e si y and ADEMA Facul y o Balea es designed and alida ed he su ey, which unde wen a p elimina y pilo s udy. Heal hca e 2024,12, 1907 3 o 12 Heal hca e 2024, 12, x FOR PEER REVIEW 3 o 12 (A) (B) (C) (D) Figu e 1. (A,B) Ini ial s age o deep ca ies in a second pe manen mola . (C,D) Too h ea ed wi h selec i e ca ies emo al, bioac i e ma e ial (Bioden ine( )) applica ion, and illed wi h bulK ill. The su ey was di ided in o h ee pa s o achie e he objec i es. The i s pa aimed a knowing he esponden 's cha ac e is ics and consis ed o 4 ques ions. The second pa was based on he clinical case o a 25-yea -old pa ien wi h an ac i e, deep, and ca i a ed ca ies in 4.7 wi h sensi i i y and ood e en ion (Figu e 1A). This had posi i e bu sligh ly inc eased i ali y es s. In he pe iapical adiog aph, deep demine aliza ion can be ob- se ed e y close o he pulp ca i y (Figu e 1B). No widening o he pe iodon al ligamen o pe iapical lesions was obse ed. Gi en his clinical si ua ion, 7 ques ions we e o mu- la ed ocused on knowing he a i ude o he den is s and esponding o he seconda y objec i es. In he hi d pa , he conse a i e clinical esolu ion and minimal in e en ion ca ied ou in he clinical case we e p esen ed (Figu e 1C,D); om he e, 1 ques ion was asked o gauge he esponden s’ opinions. The su ey was emailed na ionwide o he den is s in he “Odon ólogos de hoy” magazine da abase in Ap il 2022. Su eys ha we e no comple ed o had any e o s we e excluded. A desc ip i e s a is ical s udy was conduc ed, and he esul s we e analyzed using he SPSS 29.0 p og am. The pe cen age alues o equencies and he chi-squa e es o assess he di e ences in p e alence we e analyzed using a alue o p < 0.05 as s a is ically signi ican . Figu e 1. (A,B) Ini ial s age o deep ca ies in a second pe manen mola . (C,D) Too h ea ed wi h selec i e ca ies emo al, bioac i e ma e ial (Bioden ine( )) applica ion, and illed wi h bulK ill. The su ey was di ided in o h ee pa s o achie e he objec i es. The i s pa aimed a knowing he esponden ’s cha ac e is ics and consis ed o 4 ques ions. The second pa was based on he clinical case o a 25-yea -old pa ien wi h an ac i e, deep, and ca i a ed ca ies in 4.7 wi h sensi i i y and ood e en ion (Figu e 1A). This had posi i e bu sligh ly inc eased i ali y es s. In he pe iapical adiog aph, deep demine aliza ion can be obse ed e y close o he pulp ca i y (Figu e 1B). No widening o he pe iodon al ligamen o pe iapical lesions was obse ed. Gi en his clinical si ua ion, 7 ques ions we e o mula ed ocused on knowing he a i ude o he den is s and esponding o he seconda y objec i es. In he hi d pa , he conse a i e clinical esolu ion and minimal in e en ion ca ied ou in he clinical case we e p esen ed (Figu e 1C,D); om he e, 1 ques ion was asked o gauge he esponden s’ opinions. The su ey was emailed na ionwide o he den is s in he “Odon ólogos de hoy” magazine da abase in Ap il 2022. Su eys ha we e no comple ed o had any e o s we e excluded. A desc ip i e s a is ical s udy was conduc ed, and he esul s we e analyzed using he SPSS 29.0 p og am. The pe cen age alues o equencies and he chi-squa e es o assess he di e ences in p e alence we e analyzed using a alue o p< 0.05 as s a is ically signi ican . Heal hca e 2024,12, 1907 4 o 12 3. Resul s The su ey was answe ed by 347 den is s; he esul s a e shown in Table 1. A o al o 93.95% o hose su eyed s a ed ha hey apply minimal in e en ion concep s in hei ea men s, wi h 90.49% pe o ming conse a i e den is y ea men s daily. Rega ding academic aining, 56.48% had a bachelo ’s deg ees, 12.39% had g adua ed, 33.14% had a pos g adua e deg ee, 38.90% had a mas e ’s deg ee, and 17% had a doc o a e. Rega ding yea s o p o essional p ac ice, mos (40.63%) we e in p o essional p ac ice o 16–30 yea s (Table 1). Table 1. Responses on p io knowledge and educa ional da a o he sample. Ques ions Answe s % Do you hink you apply he concep s o minimal in e en ion in you ea men s? Yes 93.95 No 3.17 Do no know, no answe 2.88 How many yea s ha e you been p ac icing p o essionally? <5 9.51 5–15 23.05 16–30 40.63 >30 26.80 Do you pe o m conse a i e den is y in you daily p ac ice? Yes 90.49 No 4.03 Only some imes 5.48 Wha uni e si y deg ee do you ha e? Ma k he answe s ha you conside 1 Deg ee 12.39 2. Bachelo ’s deg ee 56.48 3. Pos g adua e 33.14 4. Mas e 38.90 5. PhD 17.00 Rega ding he a i ude owa ds he clinical case p esen ed in ques ion 5, 54.17% would op o he p ese a ion o he pulp and he de ini i e ea men o he case wi h a di ec o indi ec pulp capping and de ini i e illing. The e we e signi ican di e ences in e ms o he yea s o p o essional p ac ice o he esponden s, wi h a p= 0.019; howe e , he e we e no signi ican di e ences in he p o essionals’ academic aining. I is impo an o highligh ha 14.70% would ini ially op o oo canal ea men as he i s ea men op ion. Rega ding he me hods and echniques o ca i y emo al, he majo i y (66.28%) would use a ound bu wi h o a ing ins umen s (blue con a-angle) and a manual exca a o , wi h p ac ically he same pe cen age using chemical me hods o de ec he ca ious lesion as hose who would no , p esen ing signi ican di e ences in academic aining (p= 0.008 and 0.048, espec i ely.) A o al o 66.86% o hose su eyed based hei ea men on clinical symp oms, wi h he pa ien ’s age, o 19.31%, being he c i e ion o de e mine he ea men , and only 12.97% basing hei ea men on he adiog aphic image o he case. The e a e signi ican di e ences wi h espec o yea s o p o essional p ac ice, bu he e a e signi ican di e ences in academic aining (p= 0.004) (Table 2). The h ee mos used ma e ials in pulp p o ec ion a e Bioden ine 38.90%, calcium hy- d oxide 26.80%, and glass ionome 21.04%, MTA 11.82%. The e we e signi ican di e ences in yea s o p o essional p ac ice (p< 0.001) bu no in academic aining (p= 0.111). The ca i a ion illing ma e ial selec ed by he majo i y was con en ional s anda d composi e, a 65.48%, ollowed by bulk composi e ill, a 31.99%. The e we e no signi ican di e ences ei he in yea s o p o essional p ac ice o academic aining. Rega ding he adhesi e echnique used, 61.67% would use uni e sal adhesi e wi h he selec i e e ching echnique, ollowed by 25.65% who would use one-componen o al e ching adhesi e, and only 10.37% would use sel -e ching adhesi e wi hou selec i e e ching. The e we e no signi ican di e ences in yea s o p o essional p ac ice, bu he e we e signi ican di e ences in academic aining (p= 0.033) (Tables 3and 4). Heal hca e 2024,12, 1907 5 o 12 Table 2. Pe cen age o esponses o he ques ionnai e on he clinical case. Ques ions Answe s % A 25-yea -old pa ien comes o he clinic because he no ices sensi i i y and ood e en ion on he igh side o he jaw. On examina ion, he pa ien p esen ed a ca i a ed ca ies lesion a 4.7, wi h sligh ly inc eased posi i e i ali y es s. Deep demine aliza ion is obse ed e y close o he pulp ca i y in he pe iapical adiog aph. No widening o he pe iodon al ligamen o pe iapical lesions is obse ed. Gi en his clinical si ua ion, which o he ollowing p ocedu es do you hink would be indica ed? 1. De ini i e illing wi hou speci ic pulp p o ec ion 7.78 2. De ini i e illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 54.17 3. Tempo a y illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 23.34 4. Pulp ea men and de ini i e ob u a ion 14.70 Wha me hods and echniques would you use o clean and disin ec ca i ies? 1. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling 13.26 2. Manual emo al using an exca a o 5.76 3. Manual emo al wi h chemical me hods and exca a o 14.12 4. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling and manual exca a o 66.28 5. Does no know/Does no answe 0.58 Would you use chemical me hods o de ec ca ious lesions and help selec i ely elimina e ca ies? Yes 48.13 No 48.70 Do no know, no answe 3.17 In deep i al ee h, he ea men ha would be indica ed is based, abo e all, on: 1. Age o he pa ien 19.31 2. Clinical symp oms 66.86 3. Clinical image o X- ay o he ca i y 12.97 4. Does no know/Does no answe 0.86 I you decide o do a illing wi h pulp p o ec ion, wha would you choose i s ? 1. Glass ionome 21.04 2. Bioden ine 38.90 3. MTA 11.82 4. Calcium hyd oxide 26.80 5. Does no know/Does no answe 1.44 Wha ype o would you choose o illing he ca i y? 1. Con en ional s anda d composi e 56.48 2. Composi e bulk ill 31.99 3. Compome 10.09 4. Does no know/Does no answe 1.44 Wha adhesi e echnique would you use? 1. Single-componen o al-e ch adhesi e 25.65 2. Sel -e ching adhesi e wi h selec i e eng a ing 61.67 3. Sel -e ching adhesi e 10.37 4. Does no know/Does no answe 2.31 The clinical case p esen ed was esol ed conse a i ely based, abo e all, on he pa ien ’s you h and he possibili ies o epa a i e den in calci ica ion. The cleaning o he ca ies was ca ied ou using an exca a o and chemical me hods. Bioden ine was used as an indi ec pulp p o ec o . The illing was pe o med wi h sel -e ching adhesi e wi h selec i e e ching and bulk ill composi e. Does you choice o ea men coincide wi h he ea men gi en o he pa ien ? Check mo e han one op ion i you conside i 1. Yes 31.70 2. Only he ca i y cleaning me hod 21.33 3. Only in he pulp p o ec o 23.34 4. Only in he adhesi e echnique 41.21 5. Only in he illing ma e ial 17.58 6. No, I do no belie e in conse a i e ea men s o his ype o ca i ies wi hou pe o ming oo canal ea men . 8.65 Heal hca e 2024,12, 1907 6 o 12 Table 2. Con . Ques ions Answe s % In he clinical image, you can see he esolu ion o he case, and in he x- ay, you can see he e olu ion one yea a e ea men . Wha do you hink? 1. Conse a i e me hods wi h he applica ion o bioac i e line s a e a eal ea men op ion o deep ca i ies, so I ag ee wi h he ea men ca ied ou . 89.63 2. I do no belie e in pulp p o ec ion, so I would pe o m oo canal ea men 0.58 3. Despi e he scien i ic e idence o bioac i e line s in pulp p o ec ions, I con inue o pe o m ea men s ha assu e me ha he pa ien will no p esen complica ions, which is why I disag ee wi h he ea men ca ied ou . 6.05 4. Does no know/Does no answe 3.75 Table 3. Responses acco ding o yea s o p ac ice. * p alue < 0.05. Ques ions Answe s <5 Yea s 5–15 Yea s 16–30 Yea s >30 Yea s % % % % p Ques ion 5 1. De ini i e illing wi hou speci ic pulp p o ec ion 0.0 11.3 5.7 10.8 0.019 * 2. De ini i e illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 60.6 62.5 55.3 43.0 3. Tempo a y illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 27.3 16.3 20.6 32.3 4. Endodon ic ea men and de ini i e ob u a ion 12.1 10.0 18.4 14.0 Ques ion 6 1. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling 9.1 15.0 14.9 10.8 0.108 2. Manual emo al using an exca a o 0.0 3.8 4.3 11.8 3. Manual emo al wi h chemical me hods and exca a o 6.1 11.3 17.0 15.1 4. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling and manual exca a o 84.8 70.0 63.1 61.3 5. Does no know/Does no answe 0.0 0.0 0.7 1.1 Ques ion 7 Yes 39.4 47.5 49.6 49.4 0.187 No 54.5 52.5 45.4 48.4 Do no know, no answe 6.1 0.0 5.0 2.2 Ques ion 8 1. Age o he pa ien 9.1 16.3 21.3 22.6 0.142 2. Clinical symp oms 60.6 68.8 69.5 63.4 3. Clinical image o X- ay o he ca i y 27.3 13.8 9.2 12.9 4. Does no know/Does no answe 3.0 1.3 0.0 1.1 Ques ion 9 1. Glass ionome 27.3 16.3 29.1 10.8 <0.001 * 2. Bioden ine 51.5 47.5 35.5 32.3 3. MTA 18.2 21.3 7.8 7.5 4. Calcium hyd oxide 3.0 12.5 25.5 49.5 5. Does no know/Does no answe 0.0 2.5 2.1 0.0 Ques ion 10 1. Con en ional s anda d composi e 54.5 57.5 52.5 62.4 0.870 2. Composi e bulk ill 30.3 31.3 35.5 28.0 3. Compome 12.1 8.8 11.3 8.6 4. Does no know/Does no answe 3.0 2.5 0.7 1.1 Heal hca e 2024,12, 1907 7 o 12 Table 3. Con . Ques ions Answe s <5 Yea s 5–15 Yea s 16–30 Yea s >30 Yea s % % % % p Ques ion 11 1. Single-componen o al-e ch adhesi e 15.2 23.8 27.7 28.0 0.177 2. Sel -e ching adhesi e wi h selec i e eng a ing 81.8 66.3 58.9 54.8 3. Sel -e ching adhesi e 3.0 7.5 12.1 12.9 4. Does no know/Does no answe 0.0 2.5 1.4 4.3 Table 4. Responses acco ding o deg ee o s udy. * p alue < 0.05. Ques ions Answe s Bachelo Pos g adua e Mas e Doc o a e % % % % p Ques ion 5 1. De ini i e illing wi hou speci ic pulp p o ec ion 8.1 11.0 6.0 6.8 0.889 2. De ini i e illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 51.5 50.7 59.5 52.5 3. Tempo a y illing wi h speci ic pulp p o ec ion (indi ec o di ec pulp capping) 24.2 20.5 22.4 27.1 4. Endodon ic ea men and de ini i e ob u a ion 16.2 17.8 12.1 13.6 Ques ion 6 1. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling 14.1 17.8 12.1 8.5 0.008 * 2. Manual emo al using an exca a o 8.1 2.7 5.2 6.8 3. Manual emo al wi h chemical me hods and exca a o 7.1 5.5 19.8 25.4 4. Con a-angle o a y ma e ial wi h ound bu o den in emo al wi h cooling and manual exca a o 70.7 74.0 61.2 59.3 5. Does no know/Does no answe 0.0 0.0 1.7 0.0 Ques ion 7 Yes 38.4 49.3 56.9 45.8 0.048 * No 54.5 49.3 41.4 52.5 Do no know, no answe 7.1 1.4 1.7 1.7 Ques ion 8 1. Age o he pa ien 21.2 6.0 20.7 25.4 0.004 * 2. Clinical symp oms 58.6 53.4 62.9 66.1 3. Clinical image o X- ay o he ca i y 18.2 2.6 16.4 8.5 4. Does no know/Does no answe 2.0 0.9 0.0 0.0 Ques ion 9 1. Glass ionome 23.2 20.5 20.7 18.6 0.111 2. Bioden ine 32.3 30.1 49.1 40.7 3. MTA 10.1 17.8 11.2 8.5 4. Calcium hyd oxide 33.3 28.8 17.2 32.2 5. Does no know/Does no answe 1.0 2.7 1.7 0.0 Ques ion 10 1. Con en ional s anda d composi e 60.6 54.8 55.2 54.2 0.169 2. Composi e bulk ill 30.3 32.9 35.3 27.1 3. Compome 6.1 12.3 7.8 18.6 4. Does no know/Does no answe 3.0 0.0 1.7 0.0 Ques ion 11 1. One-componen o al-e ch adhesi e 26.3 34.2 26.7 11.9 0.033 * 2. Sel -e ching adhesi e wi h selec i e eng a ing 55.6 53.4 66.4 72.9 3. Sel -e ching adhesi e 15.2 11.0 6.0 10.2 4. Does no know/Does no answe 3.0 1.4 0.9 5.1 4. Discussion App oaching he ea men o deep ca ies lesions is a challenge o clinicians. Be o e s a ing i , a ull clinical s udy o he s a e o ca ies ac i i y mus be ca ied ou , as well as a Heal hca e 2024,12, 1907 8 o 12 adiog aphic s udy and a ho ough pulp diagnosis [ 7 ], since he p ese a ion and i ali y o he pulp mus be he i s objec i e o he es o a i e ea men . In deep ca i ies, i is e y easy o expose he pulp h ough cleaning me hods; he e o e, he i s s ep is o de e mine he me hod and app oach o ca i y cleaning. Classically, he emo al o all he ca ious den in is ca ied ou , which in ol es he elimina ion o he a ec ed and in ec ed den in; in deep lesions, his can cause he exposu e o he pulp and, he e o e, he need o pe o m o al emo al ea men s o he pulp on many occasions. To p e en his clinical scena io, and in acco dance wi h a minimally in asi e s a egy suppo ed by bioac i e ma e ials, he echnique o selec i e ca ies emo al has gained ac ion. This me hod in ol es e aining demine alized den in o acili a e emine aliza ion h ough he applica ion o ma e ials used as ca i y bo oms, he eby a oiding he comple e emo al o ca ious den in and subsequen pulp exposu e, as ecommended by he Eu opean Socie y o Endodon ics [ 7 ]. This selec i e emo al o ca ies can be ca ied ou in a single session when he de ini i e illing is pe o med. In a ecen s udy, Sa olainen N e al. [ 8 ] concluded ha selec i e ca ies emo al in a single session is signi ican ly mo e cos -e ec i e in p e en ing oo canal ea men and pulp exposu e han g adual ca ies elimina ion. A ecen me a-analysis by González-Gil D e al. [ 9 ] was unable o demons a e signi ican di e ences be ween me hods o selec i e ca ies emo al and adi ional me hods. Howe e , he e is e idence o g ea e success in selec i e ca ies emo al, exhibi ing a lowe pe cen age o pulp exposu e. Ano he s udy by F ase J. and MacInnes A. [ 10 ] epo ed ha in he sho e m (1.5 yea s o ea men ), highe success a es a e ound in ee h ea ed wi h selec i e ca ies emo al han hose ea ed wi h classical me hods. Howe e , he esul s a e simila in he long e m (5 yea s), wi h no di e ences ound depending on he es o a i e ma e ial used. Ano he s udy by C espo-Galla do I. e al. [ 11 ] concluded ha o al ca ies emo al is he ea men o choice in ee h wi h deep lesions and e e sible pulpi is, demons a ing ha new ideas abou ca ies lesions and he mo e conse a i e app oach o deep ca ies lesions ha e no ye been inco po a ed by den is s in hei usual clinical p ac ice. I is impo an o highligh ha aining in ca iology is necessa y, since ou s udy e eals ha a signi ican pe cen age (14.70%) would di ec ly enhance he o al emo al o he pulp, and 7.78% would no use any pulp p o ec ion ma e ial. While mos den is s p io i ize pulp p o ec ion and p ese a ion, i is conce ning ha o e 20% o hose su eyed do no implemen any ea men aimed a pulp main enance in cases o deep ca ious lesions, unde sco ing he non- conse a i e app oach adop ed by a subs an ial p opo ion o den is s in ou s udy. Simila esul s we e ob ained by Elkady and Kha e [ 12 ] in a su ey o Egyp ian den is s, whe e 80.8% elimina ed ca i ies based on he ha dness and colo o he den in. In compa ison, 67% elimina ed ca ies un il ha d den in emained, no applying concep s o minimal in e en ion. Simila esul s we e ob ained by D ache SN e al. [ 13 ] in a s udy o Russian den is s. Ou indings indica e ha 93.95% o esponden s claim o implemen minimal in e en ion concep s; howe e , 14.70% would unde ake oo canal ea men o deep ca ious lesions wi h e e sible pulpi is, sugges ing a disc epancy be ween he p inciples o minimal in e en ion den is y and clinical p ac ice. These esul s align wi h he sys ema ic e iew and me a-analysis by de Mou a RC e al. [ 14 ] on den is s’ knowledge, a i udes, and p ac ices in minimal-in e en ion den is y. Mo eo e , Al-Asma AA e al. [ 15 ], in a la ge su ey o Jo danian den is s, concluded ha in ope a i e den is y, e idence-based esea ch is no implemen ed clinically. The den al cu iculum mus be cons an ly upda ed and modi ied o op imize he ela ionship be ween e idence-based den is y and clinical decision-making. Howe e , his disc epancy is no only de ec ed in he managemen o deep ca ies bu also in he managemen and a i udes owa ds incipien ca ies lesions o he managemen o pa ien s a isk o ca ies [16,17]. Ano he in e es ing poin is he use o chemical subs ances ha help elimina e ca ious lesions. One o he mos used is Papain, he e ec s o which on den in and pulp cells a e no comple ely known. Bas os, LA. e al. [ 18 ] demons a ed ha papain-based gel p esen s concen a ion-dependen cy o oxici y, wi hou a ec ing cell iabili y, o den al Heal hca e 2024,12, 1907 9 o 12 pulp cells and mac ophages. In e es ingly, he gel inhibi ed he di e en ia ion o pulp cells bu modula ed he ac i a ion o mac ophages s imula ed wi h LPS, sugges ing ha in he den al pulp issue, Papacá ie Duo ® would impai epa a i e den inogenesis bu could ac i a e mac ophages o play hei ole in de ense and in lamma ion. In a s udy examining h ee echniques o he emo al o ca ious den in, Al-Saghee RM e al. [ 19 ] de e mined ha he chemical me hod using Papain (B ix 3000) esul s in a esidual ca i y den in su ace cha ac e ized by a highe o ganic componen and educed phospha e con en , alongside mo e pe meable ubules, compa ed o o a y me hods. The esea che s sugges ha his app oach o e s a p omising s a egy o clinical den al p ac ice. Howe e , in ou esea ch, only 14.20% o esponden s would use chemical me hods and manual emo al wi h an exca a o o clean and disin ec he ca ious lesions, al hough when asked abou ques ion 7 o whe he hey would “use chemical me hods o de ec he ca ious lesion and help he selec i e emo al o ca ies”, 48.13% answe ed yes, which again demons a es ha he e is a dissocia ion be ween wha hey would p obably do and wha is ac ually pe o med, since 66.28% chose he emo al o ca ious den in wi h a con a-angle o a y ins umen wi h ound bu o den in emo al wi h cooling and a manual exca a o . The answe o ques ion 8 is in e es ing, as i e e s o wha decision-making is based on when ea ing i al deep ca ies lesions. Mos lend g ea e impo ance o he pa ien ’s clinical pic u e han o he age o he oo h when he e is scien i ic e idence p o ing ha he pa ien ’s age is undamen al o he success o di ec and indi ec pulp p o ec ion ea men s. Rega ding he ma e ial ha should be used o di ec pulp exposu es, he Eu opean Socie y o Endodon ics ecommends calcium hyd oxide, and o indi ec coa ings, calcium hyd oxide o glass ionome [ 7 ]. In ou esea ch, he mos used ma e ial is Bioden ine o 38.90% o esponden s, ollowed by calcium hyd oxide a 26.80% and glass ionome a 21.04%. Only 11.82% would use MTA, which con as s wi h he s udy by C o K e al. [ 20 ] on den is s in Finland, whe e he MTA ob ained signi ican di e ences wi h he es o he ma e ials, especially in den is s who had a ended aining cou ses. Howe e , ano he s udy in Li huania [ 21 ] yielded simila esul s o ou s, wi h 68% o den is s su eyed in 2021 using calcium silica e hyd aulic cemen s. The ecen wo k by Kune M. e al. [ 22 ] on he mine aliza ion capaci y o di e en bioac i e ma e ials concluded ha hose bes a inducing he emine aliza ion o den in a e he classic calcium silica e cemen s, achie - ing be e esul s han he ma e ials mode n esin-based bioac i e. Pi es PM e al. [ 23 ] eached simila conclusions, indica ing ha all ion- eleasing ma e ials examined in hei s udy (glass ionome cemen , calcium silicone cemen , and esin-modi ied calcium sil- icone cemen ) demons a ed mine al p ecipi a ion in demine alized den in. Howe e , calcium silica e-based ma e ials speci ically acili a ed apa i e p ecipi a ion and he g adual es o a ion o ha dness in a i icial ca ious den in lesions. Fu he mo e, a e iew on he ap- plica ion o bioac i e ma e ials in co onal den in [ 24 ] concluded ha while mos ma e ials exhibi po en ial o bioac i i y, he e is a pauci y o clinical s udies ha p o ide conclusi e scien i ic e idence. In ou s udy, we obse ed ha yea s o p o essional p ac ice o academic aining signi ican ly in luence some o he decision-making ega ding he clinical case su eyed, coinciding wi h he esul s o Vianna, RF e al. [ 25 ], who concluded ha he clinical decision- making by B azilian den is s a ies acco ding o he p o essional p o ile, mainly in ela ion o he eplacemen o es o a ions o aes he ic easons. Recen s udies aimed a s udying he clinical beha io o uni e sal den al adhesi es used wi h di e en clinical s a egies ha e de e mined ha he e is g ea e pe manence o he es o a ions when hey a e used wi h selec i e enamel e ching; howe e , hey concluded ha he clinical pe o mance o he adhesi e is good ega dless o he clinical applica ion s a egy [ 26 , 27 ]. Howe e , o he ecen esea ch has concluded ha he e en ion a e o illings is lowe when he adhesi e is applied wi h he sel -e ching s a egy. Maciel Pi es P e al. [ 28 ] concluded ha uni e sal adhesi es should be used wi hou e ching a he den in le el because hey can comp omise he quali y o he esin–den in in e ace.