Edwards D, Bailey O, Stone S, Duncan H. The management of deep caries in UK primary care: a nationwide questionnaire-based study. Int Endod J 2021; DOI: 10.1111/iej.13585.

Further education is needed.

Deep coronal caries is defined as reaching the inner quarter of dentine radiographically and bacteria are largely confined to the dentine. Extremely deep caries extends through the entire thickness of dentine and bacteria are likely to be in contact with the pulp. Selective removal of infected dentine in deep lesions, rather than total removal, reduces the risk of pulp exposure and pulpal symptoms, and increases the likelihood of maintaining vitality. Management of deep carious lesions requires a detailed history of signs and symptoms, including radiography, vitality and percussion testing. Treatment requires an aseptic technique using rubber dam and sealing the cavity with an appropriate material which prevents bacterial ingress and encourages dentinogenesis.

An e-survey was undertaken to understand primary care practitioners' practice and attitudes to the management of deep caries lesions. A total of 657 valid responses were received from a wide range of sources including NHS, private and mixed practices, military and community dentists and dental therapists. Shown a series of bitewing radiographs, 97.7% of respondents could identify deep caries. A majority would seek further information before treatment, including percussion testing (PT) but only half would undertake vitality testing with cold. Electric pulp testing (EPT) was used more frequently in non-NHS practices and by those with a postgraduate qualification.

Ten percent of NHS practitioners would place rubber dam before carious tissue removal as opposed to 44% of private practitioners and 50% of salaried practitioners. Complete, as opposed to selective removal of caries, was practised by 41% of respondents. Disinfection of dentine was rarely carried out. Beneath a direct composite restoration, more than half of respondents would place a lining material. Of those, 47% would use a resin modified glass ionomer cement (RMGIC), 20% a glass ionomer cement (GIC), 19% a calcium silicate cement (CSC) and 16% calcium hydroxide (CH). Ninety percent of respondents had access to CH but only 38% to CSC. CSCs were more likely to be available in practices located in more affluent postcodes. More respondents had access to CSCs than mineral trioxide aggregate (MTA).

These data suggest potential health inequalities between NHS and non-NHS provided services. NHS practitioners were found to be more likely to be reliant on pulpal tests of poor specificity (PT) and less likely to use EPT and thermal sensitivity testing, less likely to use rubber dam and having limited access to newer materials such as CSCs. There is an urgent need to disseminate current guidelines for the management of deep caries lesions into primary care.