Assessing Awareness, Decision-Making & Practice Patterns for Pulpotomy Versus Pulpectomy in Pediatric Endodontic Emergencies Among Dental Practitioners Across Pakistan – A Cross-Sectional Study
Main Article Content
Abstract
Background: Appropriate selection of pulpotomy or pulpectomy in pediatric endodontic emergencies depends on accurate assessment of pulp vitality, inflammation, radicular involvement, and systemic signs. Although contemporary pediatric dentistry increasingly supports conservative vital pulp therapy where biologically indicated, practice variation may persist because of differences in training, guideline awareness, diagnostic confidence, and availability of clinical resources. Objective: To assess knowledge, clinical decision-making, and self-reported practice patterns regarding pulpotomy versus pulpectomy in pediatric endodontic emergencies among dental practitioners in Pakistan. Methods: A cross-sectional online survey was conducted among 340 dental practitioners from multiple regions of Pakistan using a structured questionnaire. Data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics were calculated, and associations between total knowledge score and decision-making score were assessed using Spearman’s rank correlation and Chi-square testing. Results: Most participants correctly identified indications for pulpotomy (84.4%) and pulpectomy (91.2%), while 60.6% selected MTA/bioceramics as the material with strongest current evidence for pulpotomy success. Only 19.1% had attended relevant CME/workshops in the previous three years, and 7.4% always used rubber dam isolation. Knowledge score showed a significant positive but weak correlation with decision-making score (ρ = 0.268, p < 0.001). Knowledge level was significantly associated with decision-making category (χ² = 13.087, p = 0.001). Conclusion: Dental practitioners demonstrated good basic awareness of pulp therapy indications, but important gaps remain in continuing education, rubber dam use, guideline familiarity, and emergency decision-making. Structured training and standardized protocols are needed to improve pediatric endodontic care
Article Details
Issue
Section
This work is licensed under a Creative Commons Attribution 4.0 International License.
How to Cite
References
1. Esteve-Pardo G, Barreiro-Gabeiras P, Esteve-Colomina L. Pulpectomy vs. pulpotomy as alternative emergency treatments for symptomatic irreversible pulpitis-a multicenter comparative randomised clinical trial on patient perceptions. Clin Pract. 2023;13(4):898-913. doi:10.3390/clinpract13040082.
2. Shueb SS, Nixdorf DR, John MT, Alonso BF, Durham J. What is the impact of acute and chronic orofacial pain on quality of life? J Dent. 2015;43:1203-1210. doi:10.1016/j.jdent.2015.06.001.
3. Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, et al. European Society of Endodontology position statement: management of deep caries and the exposed pulp. Int Endod J. 2019;52(7):923-934.
4. Philip N, Cherian JM, Mathew MG, Thomas AM, Jodhka S, John N, et al. Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a noninferiority randomised controlled trial. BMC Oral Health. 2024;24(1):626. doi:10.1186/s12903-024-04411-6.
5. Coll JA, Seale NS, Vargas K, Marghalani AA, Al Shamali S, Graham L. Primary tooth vital pulp therapy: a systematic review and meta-analysis. Pediatr Dent. 2017;39(1):16-123.
6. Elhamouly Y, Adham MM, Dowidar KML, El Backly RM. Outcome assessment methods of bioactive and biodegradable materials as pulpotomy agents in primary and permanent teeth: a scoping review. BMC Oral Health. 2024;24(1):496.
7. Wang X, Xiao Y, Song W, Ye L, Yang C, Xing Y, et al. Clinical application of calcium silicate-based bioceramics in endodontics. J Transl Med. 2023;21(1):853.
8. Lone MM, Khan FR, Lone MA, Rehman M. A survey on current trends in primary tooth pulpotomy in Karachi. J Ayub Med Coll Abbottabad. 2015;27(3):643-646.
9. Wali A, Siddiqui TM, Khan R, Batool K. Knowledge, attitude, and practices of dental surgeons in managing child patients. Int J Clin Pediatr Dent. 2016;9(4):372-378. doi:10.5005/jp-journals-10005-1393.
10. Cotton KT, Seale NS, Kanellis MJ, Damiano PC, Bidaut-Russell M, McWhorter AG. Are general dentists’ practice patterns and attitudes about treating Medicaid-enrolled preschool age children related to dental school training? Pediatr Dent. 2001;23(1):51-55.
11. Baier K, Milgrom P, Russell S, Mancl L, Yoshida T. Children's fear and behavior in private pediatric dentistry practices. Pediatr Dent. 2004;26(4):316-321.
12. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. In: The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2025. p. 487-496.
13. Yildiz E, Tosun G. Evaluation of formocresol, calcium hydroxide, ferric sulfate, and MTA primary molar pulpotomies. Eur J Dent. 2014;8(2):234-240. doi:10.4103/1305-7456.130616.
14. Mainkar A, Kim SG. Diagnostic accuracy of 5 dental pulp tests: a systematic review and meta-analysis. J Endod. 2018;44(5):694-702. doi:10.1016/j.joen.2018.01.021.
15. Mashyakhy M, Boreak N, Hanbashi A, Otayf H, Alshawkani H, Chourasia H. Dentist's attitudes, practice, and barriers toward the use of rubber dam during operative and endodontic treatments: an online questionnaire survey. World J Dent. 2021;12:306-310. doi:10.5005/jp-journals-10015-1840.
16. Ahsan S, Hydrie MZI, Hyder Naqvi SMZ, Shaikh MA, Shah MZ, Jafry SIA. Antibiotic prescription patterns for treating dental infections in children among general and pediatric dentists in teaching institutions of Karachi, Pakistan. PLoS One. 2020;15(7):e0235671. doi:10.1371/journal.pone.0235671.
17. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72.
18. Afrashtehfar KI, Assery MK. From dental science to clinical practice: knowledge translation and evidence-based dentistry principles. Saudi Dent J. 2017;29(3):83-92. doi:10.1016/j.sdentj.2017.02.002.
19. Alim-Uysal BA, Dincer AN, Yurtgezen B, Guneser MB. Does the endodontic education level affect decision-making for endodontically treated teeth with apical periodontitis? A web-based survey. Int Dent J. 2021;71(6):477-483. doi:10.1016/j.identj.2021.01.003.
20. Feller L, Lemmer J, Nemutandani MS, Ballyram R, Khammissa RAG. Judgment and decision-making in clinical dentistry. J Int Med Res. 2020;48(11):300060520972877. doi:10.1177/0300060520972877.
21. Spallek H, Song M, Polk DE, Bekhuis T, Frantsve-Hawley J, Aravamudhan K. Barriers to implementing evidence-based clinical guidelines: a survey of early adopters. J Evid Based Dent Pract. 2010;10(4):195-206. doi:10.1016/j.jebdp.2010.05.013.
22. Neuppmann Feres MF, Roscoe MG, Job SA, Mamani JB, Canto GL, Flores-Mir C. Barriers involved in the application of evidence-based dentistry principles: a systematic review. J Am Dent Assoc. 2020;151(1):16-25.e16. doi:10.1016/j.adaj.2019.08.011.
23. Alfaisal Y, Idris G, Peters OA, Zafar S, Nagendrababu V, Peters CI. Vital pulp therapy-factors influencing decision-making for permanent mature teeth with irreversible pulpitis: a systematic review. Int Endod J. 2024;57:505-519. doi:10.1111/iej.14036.
24. Murdoch AIK, Blum J, Chen J, Baziotis-Kalfas D, Dao A, Bai K, et al. Determinants of clinical decision making under uncertainty in dentistry: a scoping review. Diagnostics. 2023;13(6):1076. doi:10.3390/diagnostics13061076.
25. Scalzilli P, Jara Pintos C, Flores D, Heinzmann D, Figueiredo JA, Scarparo R. Decision-making for dental pulp exposure: a survey in graduate programs at Brazilian universities. Braz Oral Res. 2022;36:e087. doi:10.1590/1807-3107bor-2022.vol36.0087.
26. Amin M, Ahmed B. Dental education in Pakistan: current trends and practices. J Coll Physicians Surg Pak. 2010;20:497-498.
27. Sutoi D, Popa DI, Cindrea CA, Trebuian CI, Williams C, Sutoi M, et al. The impact of a one-day multidisciplinary workshop on medical students’ self-assessed confidence, knowledge, and teamwork skills: a pre-post study. Adv Med Educ Pract. 2025;16:401-410. doi:10.2147/AMEP.S509297.
28. World Dental Federation FDI. Continuing dental education: adopted by the FDI General Assembly: August 2017, Madrid, Spain. Int Dent J. 2018;68(1):12-13. doi:10.1111/idj.12370.
29. Zalan AK, Bibi AS, Ismail M, Gul A, Masood S, Babar P, et al. Knowledge of general dental practitioners, postgraduate residents, and specialists from various dental specialties towards pediatric dentistry in Pakistan. J Khyber Coll Dent. 2022;12(1):47-52. doi:10.33279/jkcd.v12i1.85.
30. Rafiq M, Bukhari J, Shaukat M, Saleem M, Tahir A, Abdullah S. Knowledge, attitude and practice regarding dental pulp treatment in teaching sector of South Punjab. Pak J Med Health Sci. 2022;16:1458-1460. doi:10.53350/pjmhs221651458.
31. Lima R, Moura AP, Miranda Filho AE, Queiroz A, Nelson-Filho P, Silva L, et al. Endodontic treatments in primary teeth among Brazilian dental practitioners: a preliminary nationwide cross-sectional e-survey. Pesqui Bras Odontopediatria Clin Integr. 2026;26. doi:10.1590/pboci.2026.039.
32. Beldar TL, Jawdekar AM, Mistry LN. Success of pulpotomy with MTA in primary teeth: a systematic review and meta-analysis. Bioinformation. 2025;21(8):2574-2580. doi:10.6026/973206300212574.
33. Tawil PZ, Duggan DJ, Galicia JC. Mineral trioxide aggregate: its history, composition, and clinical applications. Compend Contin Educ Dent. 2015;36(4):247-264.
34. Kaur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine: review of literature with a comparative analysis. J Clin Diagn Res. 2017;11(8):ZG01-ZG05. doi:10.7860/JCDR/2017/25840.10374.
35. Khan FR, Mahmud S, Rahman M. The need of paediatric dentistry specialists in Pakistan. J Coll Physicians Surg Pak. 2013;23(4):305-307.
36. Javed M, Wyne A, Hassan H. Practices of dental care and treatment provided to pediatric patients in private dental clinics in Lahore, Pakistan. BioMedica. 2024;40:100-106. doi:10.24911/BioMedica/5-1156.
37. Alzain I, Albqmi SS, Alkatheeri SM. Evaluating the impact of preclinical and clinical exposure to the pediatric pulpotomy procedure on confidence among senior dental students: an analytical survey study. Clin Cosmet Investig Dent. 2025;17:85-97. doi:10.2147/CCIDE.S501541.
38. Simpson S, Wallace CK, Vernazza CR. Paediatric dentistry provision in the North East of England: workforce confidence and attitudes. Br Dent J. 2022. doi:10.1038/s41415-022-4045-9.
39. Garispe A, Sorensen C, Sorensen JR. Dental emergencies. In: StatPearls. Treasure Island: StatPearls Publishing; 2026.
40. Alhilou AM, Al-Moraissi EA, Bakhsh A, Christidis N, Näsman P. Pain after emergency treatments of symptomatic irreversible pulpitis and symptomatic apical periodontitis in the permanent dentition: a systematic review of randomized clinical trials. Front Oral Health. 2023;4:1147884. doi:10.3389/froh.2023.1147884.
41. Nagendrababu V, Dutta A, Arias A, et al. A multi-national questionnaire-based analysis of dental students' knowledge of the management of deep caries and the exposed pulp. Int Dent J. 2025;75(4):100844. doi:10.1016/j.identj.2025.100844.
42. Gadallah LK, Elbardissy A, Elyazeed MA, et al. Pulpotomy versus pulpectomy in carious vital pulp exposure in primary incisors: a randomized controlled trial. BMC Oral Health. 2024;24:354. doi:10.1186/s12903-024-04116-w.
43. Chawla S, Singhal R, Namdev R, Kumar A, Chhanna K, Kumari C. Effectiveness of pulpotomy compared with pulpectomy for irreversible pulpitis in primary teeth: a systematic review and meta-analysis. J Dent. 2026;166:106329. doi:10.1016/j.jdent.2026.106329.
44. Maldupa I, Al-Yaseen W, Giese J, et al. Recommended procedures for managing carious lesions in primary teeth with pulp involvement-a scoping review. BDJ Open. 2024;10:74. doi:10.1038/s41405-024-00259-8.
45. Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am. 2000;44(3):571-vii.
46. Igna A. Vital pulp therapy in primary dentition: pulpotomy-a 100-year challenge. Children. 2021;8(10):841. doi:10.3390/children8100841.
47. Togoo R, Nasim V, Zakirulla M, Yaseen S. Knowledge and practice of pulp therapy in deciduous teeth among general dental practitioners in Saudi Arabia. Ann Med Health Sci Res. 2012;2(2):119-123. doi:10.4103/2141-9248.105657.
48. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. In: The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2025. p. 487-496.
49. Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA; British Society of Paediatric Dentistry. Pulp therapy for primary molars. Int J Paediatr Dent. 2006;16 Suppl 1:15-23.
50. Patil PD, Katge AF, Rusawat DB. Knowledge and attitude of pediatric dentists, general dentists, postgraduates of pediatric dentistry, and dentists of other specialties toward the endodontic treatment of primary teeth. J Orofac Sci. 2016;8(2):96-101. doi:10.4103/0975-8844.195917.
51. Nayak UA, Wadhwa S, Kashyap N, Prajapati D, Mahuli AV, Sharma R. Knowledge and practice of, and attitudes toward, pulp therapy in deciduous teeth among pediatric dentists in India. J Investig Clin Dent. 2017;9(1):e12284. doi:10.1111/jicd.12284.
52. Madarati AA. Why dentists don't use rubber dam during endodontics and how to promote its usage? BMC Oral Health. 2016;16:24. doi:10.1186/s12903-016-0175-2.
53. Ahmad IA. Rubber dam usage for endodontic treatment: a review. Int Endod J. 2009;42(11):963-972. doi:10.1111/j.1365-2591.2009.01623.x.
54. Harford S, Sharpling J, Williams C, et al. Guidelines relevant to paediatric dentistry-do foundation dentists and general dental practitioners follow them? Part 2: treatment and recall. Br Dent J. 2018;224:803-808. doi:10.1038/sj.bdj.2018.355.
55. Caplan DJ, Reams G, Weintraub JA. Recommendations for endodontic referral among practitioners in a dental HMO. J Endod. 1999;25(5):369-375. doi:10.1016/S0099-2399(06)81174-X.
56. Guo J, Guo J, Yuan G. Impact of multimodal electronic follow-up systems on postoperative complications in pediatric dentistry under general anesthesia: a retrospective study. J Clin Pediatr Dent. 2025;49(4):120-127.
57. Gharechahi M, Rouhani A, Ahmadi AK, Davaji M. The necessity and reasons for referrals to endodontists among general dentists in Mashhad: a cross-sectional study. Saudi Endod J. 2024;14:75-79.
58. Kaur H, Singhal S, Glogauer M, Azarpazhooh A, Quiñonez C. General dentists' perceptions about their relationship with specialists. Int Dent J. 2022;72(4):463-469. doi:10.1016/j.identj.2021.08.052.
59. Rosenman R, Tennekoon V, Hill LG. Measuring bias in self-reported data. Int J Behav Healthc Res. 2011;2(4):320-332. doi:10.1504/IJBHR.2011.043414.