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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 228-233

Knowledge, attitude, and practice regarding nonrestorative cavity control among pediatric dentists: A questionnaire-based cross-sectional study

Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission09-May-2022
Date of Acceptance10-Oct-2022
Date of Web Publication14-Nov-2022

Correspondence Address:
Bhavya Shah
Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth Campus, Pipariya, Vadodara - 391 760, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_74_22

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Introduction: According to the worldwide burden of illnesses, unresolved dental decay is one of the most frequent oral diseases. One the significant barriers noticed during dental treatment of the children is fear and anxiety due to conventional treatment procedures. Hence, various dental caries removal and arrest techniques that are noninvasive and child friendly have to be incorporated by the pediatric dentists in their day-to-day practice. Aim: To evaluate knowledge, attitude, and practice regarding nonrestorative cavity control (NRCC) among pediatric dentists in India through the online survey. Materials and Methodology: An online questionnaire-based cross-sectional survey was carried out between January 2021 and May 2021 among the pediatric dentists in India. A structured questionnaire was used to assess the knowledge, attitude, and practice regarding NRCC technique. Self-administered questionnaire with 16 close-ended questions were formulated with multiple choice or Yes-No options. A total of 12 pediatric dentists working only as faculty, 47 only as practitioners, 39 as both faculty and practitioners, and 116 as postgraduate students participated in the study. Results: In the present study, 85% of pediatric dentists were aware about the concept of NRCC but not regarding the steps and the technique used in the concept. Most commonly chosen cariostatic agent was silver diamine fluoride (95.3%) followed by sodium fluoride varnish (86.9%) to use at concentrations 38% and 5%, respectively. 55.6% of the respondents stated that NRCC had various advantages which gave the technique an edge over other conventional techniques, whereas food impaction following slicing of the teeth (52.8%) was the most common disadvantage of this technique. Conclusion: The detailed knowledge related to NRCC is poor and misunderstood by most of the participants; hence, it warrants for the need to increase the awareness regarding this child friendly technique and motivate the pediatric dentists in using the same.

Keywords: Caries control, minimal invasive dentistry, nonrestorative cavity control, silver diamine fluoride, sodium fluoride varnish

How to cite this article:
Shah B, Poonacha K S, Deshpande A, Dave B, Jaiswal V, Deshmukh S. Knowledge, attitude, and practice regarding nonrestorative cavity control among pediatric dentists: A questionnaire-based cross-sectional study. J Dent Res Rev 2022;9:228-33

How to cite this URL:
Shah B, Poonacha K S, Deshpande A, Dave B, Jaiswal V, Deshmukh S. Knowledge, attitude, and practice regarding nonrestorative cavity control among pediatric dentists: A questionnaire-based cross-sectional study. J Dent Res Rev [serial online] 2022 [cited 2023 Jan 30];9:228-33. Available from: https://www.jdrr.org/text.asp?2022/9/3/228/361140

  Introduction Top

Dental caries is caused by organic acids released by micro-organisms by causing demineralization of enamel surface. It progresses from the external surface to the underlying vital tissue, producing discomfort and swelling. In 2020, the global prevalence of dental caries in primary and permanent teeth was estimated at 46.2 and 53.8%. Dental phobia, financial constraints, planning challenges, and commuting issues have been identified as the important obstacles to children's dental care, as per parental observations.[1]

The hypothesis of biofilm topping the carious lesion being the driving force of the carious process, rather than bacteria in diseased dentin is the foundation for minimal invasive intervention treatments. The frequent elimination or disruption of this biofilm by brushing with a fluoridated toothpaste delays or even brings the carious process to a pause. This brings us to the new method of caries control named nonrestorative cavity control (NRCC).[2]

For primary and permanent dentition, NRCC is a three-part treatment approach. The first part is concerned with the patient's oral hygiene procedures or improvements in oral hygiene maintenance. The second part is the lesion exposure method where exposure of the cavity is carried so that it is accessible for the toothbrush in maintaining the oral hygiene. The third step involves applying a 38% silver diamine fluoride (SDF) or a 5% sodium fluoride (NaF) varnish to possibly stop the carious lesion while it is active or if there is a greater risk of recurrence.[3]

In young children with active, cavitated caries lesions in the primary dentition and/or dental anxiety, NRCC is recommended. It focuses on treating the etiology of decay over time, minimizing child's distress and encourages oral health. It requires some particular measures to control cavitated caries lesions with restoration being a minor priority.[4]

Hence, the aim of the study was to evaluate knowledge, attitude, and practice Regarding NRCC technique among pediatric dentists in India through the online survey.

  Materials and Methodology Top

A 19-item questionnaire on NRCC was prepared consisting of two parts. The first part consisted of demographic data and the next part included both multiple choice and close-ended questions with an intention to know the knowledge and attitude regarding NRCC from the participants. The questionnaire study was conducted among the pediatric dentists through an online platform via Google form from January 2021to March 2021. This study was registered and ethical approval obtained from Sumandeep Vidyapeeth Institutonal Ethics committee (SVIEC/ON/DENT/SRP/20145).

Pediatric dentists working as faculty members or having a private practice or postgraduate students pursuing masters in the field of pediatric dentistry and those who gave consent were included in the study. Those who did not completely fill the form were excluded from the study. To ensure privacy and confidentiality, individual results were not made public in any way.

The questionnaire was self-prepared with reference from the key article. Professors, Readers, and Senior Lecturers from the same institute's department of pediatric and preventive dentistry validated the content. Following that, a pilot study with a sample size typical of the population was conducted to validate the same questionnaire at the very same time. All contents of questionnaire with respect to multiple options were checked by the experts and was statistically validated by obtaining a Cronbach's Alpha value of 0.7 calculated by the formula = [INLINEL:1]

Statistical analysis

The collected data were entered in SPSS 18.0 Software, (IBM, New York, USA). SD and results on categorical measurements were presented in number (n) and percentage (%). Level of significance will be fixed at P = 0.05 and any values ≤0.05 were considered to be statistically significant. The validity of study parameters on a categorical scale was determined using the Chi-square analysis. The significance of research parameters on a continuous scale between two groups (intergroup analysis) on metric parameters was determined using a Student's t-test (two tailed, independent).

  Results Top

There were 146 males and 68 females among the 214 participants in the study, with 12 working as only faculty, 47 as only practitioners, 39 as both faculty and practitioners, and 116 as postgraduate students. The work experience for <5 years was 12.8%, 44.7%, and 85.3% for the group of both faculty and practitioner, only practitioner, and postgraduate students, respectively. The work experience for more than 5 years was 66.7%, 48.7%, 14.9%, and 14% for the groups only faculty, both faculty and practitioner, only practitioner and postgraduate students, respectively. With a P = 0.001, the results were statistically significant [Table 1].
Table 1: The demographic data

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Questions 4, 5, and 6 evaluated the knowledge regarding the terminologies used depending upon the extent of caries where 59.3% chose NRCC for the extent into enamel, 50% chose nonrestorative caries treatment for the depth into dentin. Ninety-two percent responded choosing NRCC when the caries involved both enamel and dentin or only into enamel. All the results of the above-mentioned question were statistically significant [Table 2].
Table 2: Knowledge, attitude and perception regarding the nonrestorative cavity control technique among the participants and comparison done by statistical analysis using Chi-square test with significance (P<0.05)

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Among the various cariostatic agents mentioned in the literature, 95.3% of the total participants chose SDF, followed by 86.9% who chose NaF varnish, 45.8%, 28.9%, 11.2%, and 1.9% who chose CPP-ACP, APF gel, ammonium fluoride, and don't know, respectively. Among all the options for the concentration of SDF and NaF, 57% of total participants voted it to be 38% and 5% concentration of SDF and NaF varnish, respectively [Table 2].

Plaque control and oral hygiene maintenance in children, as well as the knowledge and attitude of parents or caregivers, are both necessary for the successful outcome of NRCC, according to 76% of total participants. According to 95% of all participants, NRCC could be considered as a treatment option in their practice [Table 2].

Among the various advantages noted in the literature and the question being a multiple choice question 18.7% opted for cost-effective and less time-consuming, 27.6% opted for it being a child friendly treatment as no drilling or anesthesia is needed, 15.4% opted for it helping to preserve the functionality of the tooth until exfoliation without causing pain or inflammation, 25.2% thought it to be minimally invasive and 55.6% said that all the above-mentioned options as being the advantages that gives NRCC an edge over other techniques [Table 2].

Among the various disadvantages noted in the literature and the question being a multiple choice question 42.5% opted for progression of caries, 50.5% opted for space loss by mesial drift, 52.8% opted for food impaction following slicing, 34.6% opted for lesion sensitivity after slicing 27.6% said that a restoration would be preferable because it facilitates plaque control and 16.8% thought that once the tooth is sliced, restoration is often not possible and extraction is the only remaining alternative. These are the disadvantages of NRCC over other techniques. According to 85% of total participants NRCC should be included in the curriculum [Table 2].

A statistically significant difference was seen in the questions 4, 5, 6, 8, 9, 11, 14, 15, and 16 in relation to the knowledge attitude and practice regarding the NRCC technique (P < 0.05). However, no statistically significant difference was seen in the other questions [Table 2].

  Discussion Top

The purpose of this study was to find out how well postgraduate students, faculty members, and private practitioners in the field of pediatric dentistry knew regarding the NRCC technique. The current study was undertaken to evaluate the knowledge using a self-prepared questionnaire. Based on the validation technique described previously, the questionnaire used in this study was content and face validated before the start of the study. The goal of this validation process was to get expert feedback and make changes to the questionnaire to make it easier to understand.

Interrupting the progression of caries disease has long been associated with restorative surgical treatment. The basic idea was to create enough room for the insertion of a restorative material and halt the progression of caries by the removal of decayed dentin.[5] NRCC, on the other hand, is a casual approach that aims at improving oral health and keeping the teeth functional. As G.V. Black noted in his book published in 1908, NRCC is not a novel concept.[6] “Any decayed buccal and labial cavities should be properly opened by trimming away all overhanging enamel and leaving as wide an opening as possible to allow free washing, both in synthetic and in fresh clean saliva.”

The participants in the current study had significant differences of opinion about the application technique and the various cariostatic agents used in the study. A study done by Kher and Rao[7] elaborated the technique being in the following order: 1st step-oral hygiene maintenance (using fluoridated toothpaste), 2nd step cavity accessibility, and 3rd step-SDF or NaF varnish application and the maximum chosen option in the current study was in accordance with the previously mentioned technique.

The participants in the current survey voted for NaF varnish and SDF as cariostatic agents to be used at a concentration of 5% and 38%, respectively. These results were in accordance with a systematic review and network Meta-analysis done by Urquhart et al.[8] The purpose of nonrestorative or microinvasive caries treatment, according to him, is to regulate the caries disease process at the lesion level while minimizing the loss of healthy tooth structure. Low-level evidence revealed that 5% NaF Varnish was most effective in stopping or reversing a noncavitated carious lesion, and some high-level evidence favoring biannual application of 38% SDF for established cavitated lesions. The entire purpose of a caries management plan, however, is to avoid the onset of caries.

Several studies compared NRCC with various different caries control and prevention methods. A study done by Mijan et al.[9] evaluated and compared the survival percentages of the conservative restorative treatment using amalgam, ART approach, and ultra conservative treatment (UCT) (small cavities treated with ART and large cavities were treated with NRCC). With no significant difference at the end of 3.5 years, they stated that UCT can also be alternative treatment option in treating primary molar teeth. Santamaria et al.[10] conducted a randomized clinical trial, comparing three treatment protocols that is conventional restoration (CR) (compomer), Hall Technique (HT), and NRCC in children with a high caries risk. The HT was found to be superior in the tests (2.5% major failures). There was no significant difference in the percentage of failures between the conventional and NRCC treatments (abscesses, pulpal complaints, or necessity for a endodontic treatment).

A study done by Bianchi et al.[11] checked the impact of NRCC on proximal carious lesions of primary anterior teeth and the researchers found that NRCC could be a promising choice for treating carious lesions on the proximal surfaces of primary teeth, and that it would be well appreciated by both children and their parents/legal guardians.

Slayton et al.[12] in accordance with American Dental Association produced an evidence-based clinical practise guideline on nonrestorative therapies for carious lesions. The panel concluded that the use of 38% SDF, 5% NaF varnish, 1.23% acidulated phosphate fluoride gel, and 5000 parts per million fluoride (1.1% NaF) toothpaste or gel, among other interventions, were the most efficient in decreasing the caries index.

Santamaria et al.[13] assessed the behavior and pain perception of the child while performing different caries management strategies such as HT, NRCC and CR. The results suggested children showed more negative behavior in CR compared to NRCC and HT. They concluded that NRCC and HT group were pain free compared to the conventional treatment which gives them edge over others and as an pediatric dentist these techniques also help us to mould the behavior of a child.

Various advantages and disadvantages have been mentioned in the literature. The ability to handle a cavitated carious lesion without placing a restoration and sometimes avoiding restorative therapy under general anesthesia, as well as the opportunity to postpone or avoid restorative treatment, are all advantages to the patient. It is possible to avoid a restorative cycle that's either ineffective or harmful. In addition, fear-inducing restorative procedures may not be essential for younger children, and the child may benefit from better self-care over the course of their lifetime, which is key for NRCC success and maintaining a healthy dentition. To implement NRCC successfully, parents/caregiver or patient cooperation is required. This involves a careful selection of cases (possibly even more so than with ART or the HT), as well as thorough monitoring of the lesion's activity. It also requires a committed dentist/oral health worker who is always developing his or her personal health education abilities.[14]

It is important to emphasize that the present study was a crosssectional study, which evaluated the knowledge in only pediatric dentists in India. Hence, further longitudinal investigations involving the views of pediatric dentists from all over the world on making the use of this technique as one of the caries management strategies in regular dental practice is further required owing to the various advantages and disadvantages mentioned in the literature.

  Conclusion Top

The results of the study were promising in terms of NRCC technique awareness, but not in terms of procedure of NRCC to be done in children. Arresting the cariogenic process at the lesion level management requires efforts by both the dentist and the patient in their domains.

SDF was the most accepted cariostatic agent chosen by 95.3% of the participants followed by NaF varnish chosen by 86.9% of the participants. If plaque control and oral hygiene maintenance are achieved in children, and the parents or caregivers are well aware of this minimally invasive technique to be followed and take an active role in maintaining oral hygiene, then NRCC can be a considered a patient-friendly treatment. As no drilling or anesthesia is required, 95% of the participants believe it will become a popular caries management strategy in the near future.

Most of the participants had a limited understanding of NRCC, necessitating the need to raise awareness of this child-friendly technique and encourage more pediatric dentists to use it.

Ethical statement

Sumandeep Vidyapeeth Institutonal Ethics committee (SVIEC/ON/DENT/SRP/20145).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kazeminia M, Abdi A, Shohaimi S, Jalali R, Vaisi-Raygani A, Salari N, et al. Dental caries in primary and permanent teeth in children's worldwide, 1995 to 2019: A systematic review and meta-analysis. Head Face Med 2020;16:22.  Back to cited text no. 1
Innes NP, Frencken JE, Bjørndal L, Maltz M, Manton DJ, Ricketts D, et al. Managing carious lesions: Consensus recommendations on terminology. Adv Dent Res 2016;28:49-57.  Back to cited text no. 2
Schwendicke F, Frencken J, Innes N, editors. Caries excavation: Evolution of treating cavitated carious lesions. Monogr Oral Sci Basel 2018;27:124-36.  Back to cited text no. 3
Gruythuysen RJ. Non-restorative cavity treatment. Managing rather than masking caries activity. Ned Tijdschr Tandheelkd 2010;117:173-80.  Back to cited text no. 4
Hernández M, Marshall TA. Reduced odds of pulpal exposure when using incomplete caries removal in the treatment of dentinal cavitated lesions. J Am Dent Assoc 2014;145:574-6.  Back to cited text no. 5
Black GV. A Work on Operative Dentistry. 3rd ed. Chicago: Medico-Dental Publishing; 1908.  Back to cited text no. 6
Kher MS, Rao A. Lesion management in pediatric dentistry: Non-restorative cavity control. Clin Den Rev 2019;3:1-10.  Back to cited text no. 7
Urquhart O, Tampi MP, Pilcher L, Slayton RL, Araujo MW, Fontana M, et al. Nonrestorative treatments for caries: Systematic review and network meta-analysis. J Dent Res 2019;98:14-26.  Back to cited text no. 8
Mijan M, de Amorim RG, Leal SC, Mulder J, Oliveira L, Creugers NHJ, et al. The 3.5-year survival rates of primary molars treated according to three treatment protocols: A controlled clinical trial. Clin Oral Investig 2014;18:1061-9.  Back to cited text no. 9
Santamaría RM, Innes NP, Machiulskiene V, Schmoeckel J, Alkilzy M, Splieth CH. Alternative caries management options for primary molars: 2.5-year outcomes of a randomised clinical trial. Caries Res 2017;51:605-14.  Back to cited text no. 10
Bianchi RM, Pascareli-Carlos AM, Floriano I, Raggio DP, Braga MM, Gimenez T, et al. Impact of non-restorative cavity control on proximal carious lesions of anterior primary teeth on the tooth survival and patient-centered outcomes (CEPECO 2): Study protocol for a non-inferiority randomized clinical trial. BMC Oral Health 2021;21:167.  Back to cited text no. 11
Slayton RL, Urquhart O, Araujo MW, Fontana M, Guzmán-Armstrong S, Nascimento MM, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American dental association. J Am Dent Assoc 2018;149:837-49.e19.  Back to cited text no. 12
Santamaria RM, Innes NP, Machiulskiene V, Evans DJ, Alkilzy M, Splieth CH. Acceptability of different caries management methods for primary molars in a RCT. Int J Paediatr Dent 2015;25:9-17.  Back to cited text no. 13
van Strijp G, van Loveren C. No removal and inactivation of carious tissue: Non-restorative cavity control. Monogr Oral Sci 2018;27:124-36.  Back to cited text no. 14


  [Table 1], [Table 2]


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