INTRODUCTION

Clinical decision-making, which is a relevant area of healthcare, is based on both clinical and non-clinical factors ¹ . Non-clinical factors are subjective determinants such as time since graduation or patient socioeconomic status ¹ . Thus, the clinical decisions regarding techniques and materials may vary according to the profile of both patients and professionals. Knowledge of the factors involved in this process is relevant to defining behavior and implementing more effective strategies for promoting healthcare services ² . Dental professionals are strongly encouraged to apply evidence-based dentistry (EBD) when making decisions ³ . Nonetheless, most dental treatments cannot be truly described as based on experimental evidence ³ . Diagnostic errors are common and recognized as a source of preventable adverse events, but they are rarely evaluated because of the complex decision-making process ⁴ . In this regard, the factors associated with dental clinical decision-making still need to be explored.

The concept of EBD advocates minimally invasive dentistry, and adoption of a philosophy of prevention and avoidance of invasive treatments, with minimum removal of healthy tissues ⁵ . Some studies have associated several subjective determinants to dentists’ decisions on whether to treat patients with either more aggressive or more conservative approaches ^{1, 2} . However, literature is still scarce on other factors such as the association between graduate programs and the application of minimally invasive dentistry.

Another point that requires further study is dental professionals’ clinical decision-making regarding esthetics. Some studies have detected the controversial replacement of satisfactory amalgam restorations by composite resins because of amalgam’s inferior esthetics ^{2, 6} . The current study evaluates whether non-clinical subjective factors influence the treatment decision-making of Brazilian dentists based on technical and esthetic matters.

MATERIALS AND METHODS

This study was approved by the University Ethics Committee (32149220.7.0000.5291). The present research is a cross-sectional analysis based on a self-administered electronic questionnaire.

Development and structure of the data collection instrument

The data collection instrument was developed following a strict order to ensure reliability of results: (1) Establishment of conceptual structure, objectives of the instrument and target population, (2) Preparation of the questionnaire, (3) Application of the questionnaire to scientific consultants, (4) Pre-testing of the questionnaire with the target population, (6) Sample calculation, and (7) Data collection.

The data collection instrument was prepared according to the definitions and objectives established. The instrument was divided into 2 sections: the consent form and the questionnaire. After receiving an invitation to participate in the survey, participants accessed the informed consent form, which presented the objectives, methods, risks, and benefits of participating in the study. The professionals were only redirected to the questionnaire if they chose to participate voluntarily in the research. For the second section, extraoral and intraoral photographs obtained with informed consent from 2 patients were used to produce a clinical case with technical and esthetic questions. Treatment 1 (T1) of the clinical case involved the right mandibular first molar, which showed significant destruction of more than 2/3 of the crown and associated spontaneous pain (Fig. 1). Treatment 2 (T2) involved the adjacent right mandibular premolars, which had extensive Class II cavities with amalgam restorations and no carious lesions or any other associated complaint (Fig. 2). After preparing the clinical case, questions were developed based on a previously validated questionnaire ² and literature review. The most appropriate treatment decisions for T1 and T2 were defined as root canal treatment followed by indirect restoration ⁷ and no treatment ^{2, 8} , respectively.

Fig. 1 Clinical case 1 presented in the questionnaire (T1), showing the intraoral occlusal view of the right mandibular first molar with extensive crown destruction. 

Fig. 2 Clinical case 2 presented in the questionnaire (T2). (a) Intraoral occlusal view of the right adjacent mandibular premolars showing extensive Class II cavities with amalgam restorations. (b) Extraoral right buccal view focusing on amalgam pigmentation of premolars. 

Statistical analysis

Data were processed using Excel software (Microsoft, Redmond, WA, USA) and analyzed with IBM SPSS 22 statistical software (IBM Corporation, Armonk, NY, USA). Chi-square test and Fisher’s exact test were used to analyze T1. For analysis of T2, a qualitative index presenting scores of 1 to 5 was developed to categorize the proposed treatment according to the loss of tooth tissues. Score 1 represented the lowest level of tooth tissue destruction (No treatment necessary), whereas score 5 characterized the most aggressive approach (Replacement with ceramic crown). Then, one-way analysis of variance was applied and, for the pairwise comparison of groups, the post-hoc Tamhane test was used. The significance level established for all analyses was a = 5%.

Table 1 Sociodemographic and professional characteristics of the study population (n = 

RESULTS

The electronic questionnaire was viewed by a total 1157 participants, of whom 385 started and 302 completed it (Completion rate = 78.4%). Average time spent answering the questionnaire was 4 minutes. The sociodemographic and professional characteristics of the participants are shown in Table 1. Most participants graduated 20+ years prior to this survey (61.6%) and worked in a private practice (64.6%). Most participants had completed a Post-Graduate Program/dental residency (92.4%).

The main choices for T1 and T2 were, respectively, “Root canal treatment followed by indirect restoration” (73.5%) and “No treatment needed” (55.3%) (Table 2).

Table 2 Distribution of treatments proposed by dentists for the clinical cases presented in the questionnaire: 

Table 3 Treatments proposed for T1 (molar) according to the Brazilian region of clinical practice: 

Table 4 Treatments proposed for T2 (Premolars) according to the area of Dental Residency Graduate Program of the study participants: 

The clinical decision-making for T1 was significantly influenced by the Brazilian región of clinical practice (p=0.005) (Table 3). In T2, having completed a residency program in Operative Dentistry (p=0.035) (Table 4), private practice (p=0.033) and most patients having higher estimated socioeconomic level represented by class A/B1 (household income above $4350) (p=0.002), significantly increased the loss of tooth tissues with the treatment proposed (Table 5). Most specialists in Operative Dentistry (58.6%) had graduated 20+ years ago, followed by 11 to 19 years for 16.8% of the respondents.

Table 5 Analysis of subjective determinants that showed differences between the treatments proposed in T2 (Premolars): 

DISCUSSION

The results of this study indicated an association between some of the non-clinical factors tested and the treatments proposed in both T1 and T2. This is supported by the literature, in which determinants such as patients’ skin color were also associated to dentists’ clinical decision-making ^{1, 2} . The treatment proposed for the mandibular molar with extensive crown destruction and spontaneous pain indicative of irreversible pulpitis, presented in T1, had greater agreement among the study participants than T2. Only 3 professionals (1.0%) indicated T1 as tooth extraction followed by dental implant, whereas 299 dentists (99.0%) opted for more conservative treatments (root canal treatment followed by some type of crown restoration). This finding is favorable because the option of tooth extraction is considered an overtreatment for the case presented ⁷ . The only sociodemographic determinant that influenced the results of T1 was the Brazilian region of clinical practice. The growing regional differences in the index of decayed, missing and filled teeth (DMFT) of the Brazilian population may reflect the clinical routine and beliefs of professionals regarding treatments. The difference in the DMFT index among the Brazilian north and southeast regions was close to 20% in 1986, but this percentage increased considerably to 26% in 2003 and 43% in 2010 ¹⁰ . The worst DMFT indexes are in the north and northeast regions due to spatial autocorrelation with low levels of access to dental care and higher levels of poverty, illiteracy, and lower levels of education ^{10, 11} . As a result, the northeast and north regions present a higher level of caries disease and a lower proportion of restored teeth compared to the southeast ^{10, 11} .

In T2, the most prevalent treatment selected for the maxillary premolars with amalgam restorations was “no treatment necessary” (55.3%), followed by “finishing and polishing” (24.2%). These options are also consistent with current concepts of minimally invasive dentistry supporting the removal of the least possible amount of healthy dental tissues. However, replacement of the satisfactory amalgam restoration by composite resin, ceramic dental crown, and ceramic onlay were selected, respectively, by 39 (12.9%), 12 (4.0%), and 9 dentists (3.0%); adding up to the considerable number of 60 dentists (19.9% of the total sample) selecting a procedure that is not justified. The esthetic component is subjective and depends on individual perception, and no complaint was associated to the restorations.

The motivation and effects of the specific barriers in the implementation of evidence-based dentistry should be investigated in future studies because dentists may be overestimating treatment options when compared to laypeople’s perception of smile. The clinical decision to replace restorations, particularly those that do not have an associated infection, should always be based on high professional criteria and consideration of patient feedback to avoid misconceptions. Restoration substitutions should be avoided because they usually result in increasing cavity size, and thus in loss of healthy tooth structure, easily leading to a costly, repetitive restorative cycle ^{8, 12} . Esthetics play an important role in people’s lives and are directly associated with quality of life ¹³ . Some authors have suggested that the cosmetic industry and the dental profession have leveraged this importance to increase demand and, consequently, profits ^{2, 6} .

The clinical decisions made for T2 showed greater influence of subjective determinants. Having completed a residency program in Operative Dentistry significantly raised the mean aggressiveness of the treatment proposed. Most Operative Dentistry specialists would recommend “no treatment necessary” (38.6%), but this percentage was the lowest among all areas of Dental Residency Program. At the same time, Operative Dentistry professionals were the most likely to select the treatment options “finishing and polishing” (34.3%) and “replacement with composite resin” (21.4%), involving higher scores for tooth tissue loss, compared to other professionals. Generally, Operative Dentistry specialists routinely check restorations and esthetic dental procedures, resulting in a high level of smile esthetic demand ¹⁴ . The finishing and polishing procedure is considered favorable because it reverses the decision to replace old amalgam restorations and may extend the durability of restorations ^15-17 , but it can cause loss of tooth tissue, contradicting the principles of minimally invasive, evidence-based dentistry. The choice of Operative Dentistry professionals to replace the presented amalgam restoration with composite resin may be explained by the differences among dentists in the esthetic perception of smiles, which is significantly impacted by the highest degree they have earned and area of clinical practice ^18-19 .

Other determinants that increased the rate of tooth tissue loss in T2 were private practice and having more patients of high socioeconomic level (as estimated by respondents). The high cost of esthetic dental treatments and the difference in DMFT index according to socioeconomic status may explain these findings ¹¹ .

The choice of treatment was more conservative in the present study than in the study by Chisini et al. ² . This may be related to the information provided, considering that our study stated that the patient did not report any symptoms or complaints associated with these teeth, including esthetic factors. Another explanation may be related to the population evaluated, considering that the present study surveyed the entire national territory, not just the northeast and south regions.

This study used an electronic questionnaire because it provides fast, accurate data; is affordable, and follows the technological and dynamic trends of scientific method ^{20, 21} . Based on these characteristics, electronic questionnaires are preferred by most participants in epidemiological studies ²² . Traditional approaches (e.g., face-to-face interviews, telephone interviews and printed questionnaires) have shown a gradual reduction in participation rates, mainly in the last decade ^{23, 24} . Among the reasons suggested for the drop in response rates are the greater demand for participation in surveys, the use of smartphones, and a general decrease in volunteering ²⁴ . It is also important to consider the challenges of conducting traditional interviews during the coronavirus (COVID-19) pandemic, which has had unprecedented effects on society. COVID-19 led to a massive rise in survey-based analysis, and the resources to conduct ethical, reliable, accurate research on digital platforms are increasingly being emphasized and explored ²¹ .

The strict sequence used to develop the data collection instrument for this study aimed to ensure the reliability of the method ²⁵ . Questionnaire items were constructed and organized based on a pre-existing questionnaire and literature review ² . Literature review is the most frequently used method for developing survey-based analysis instruments, though it is also appropriate to use an existing questionnaire resource because it ensures that the questions have been previously tested for psychometric qualities ²⁵ . The application of the questionnaire to scientific consultants and the pre-testing stage with the target population, prior to data collection, are essential steps in survey-based methods. In conclusion, dentists’ clinical decision-making varies according to professional profile, mainly regarding the replacement of restorations because of esthetic concerns. Having completed a residency program in Operative Dentistry, working in the private sector, and most patients having a high estimated socioeconomic level are factors that reduce the use of minimally invasive dentistry in esthetic treatments.