Knowledge and attitudes toward evidence-based cariology and restorative dentistry among Egyptian dental practitioners: a cross-sectional survey

Background This is the first study to assess Egyptian dental practitioners’ knowledge about conservative caries management approaches and investigate whether this knowledge transfers into clinical practice and the barriers to translating research into evidence-based practice. Methods A sample of dental practitioners was surveyed using an online questionnaire. Convenience and snowball sampling were used to collect data from February to June 2022. We included graduated dentists from Egyptian universities who practiced in Egypt. Data were analyzed with descriptive statistics, and the associations between variables were checked using Kruskal Wallis and Chi-Square tests. Results This study included 396 participants from throughout Egypt. There were significant correlations between specialty and participants’ knowledge and behaviors toward evidence-based caries management (p = 0.002) and between specialization and tools used to detect carious lesions (p < 0.001). Most participants (59.1%) used G.V Black’s classification, and (80.8%) removed caries based on the feature of dentin hardness and color, whereas (67%) removed caries until hard dentine remained. The participants’ primary hurdle to staying up-to-date was their belief that the newly gained information would not be clinically applicable due to a lack of equipment or working in low-economic areas. Patient-related barriers were the major obstacles for participants in implementing evidence-based practice. Conclusion Egyptian dentists did not fully embrace minimal invasive approaches for caries management, and practitioners’ experiences continue to shape decision-making. It emphasizes the imperative to practically educate dentists using effective knowledge translation dissemination to promote evidence adoption in daily practice and advocate value-based dental care to address the economic crisis’s impact on Egypt’s healthcare. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-023-03333-z.


Introduction
Dental caries remains a significant health problem worldwide [1], affecting 60-90% of children and the majority of adults [2].There are health inequalities in dental caries burden in both children and adults [3], particularly most prevalent in low-income communities due to unaffordable dental care [4,5].As such, 2.4 billion people (35% global prevalence) had carious permanent teeth without treatment, making it the most common medical condition [6].Hence, dental caries poses a global health burden for numerous people who require proper treatment to improve their quality of life, particularly those who cannot afford dental care [3,7,8].Similarly, dental caries remains a crucial health concern in Egypt, particularly among vulnerable populations (e.g., women and persons with low socioeconomic status), with approximately 70.3% having at least one untreated carious tooth [9].
Caries-management concepts have shifted substantially in recent years towards a deeper understanding of caries' pathophysiology and tissue healing capabilities, resulting in more conservative approaches [10,11].Minimal intervention dentistry was developed to address the deficiencies in the traditional operative concept ("drill and fill") by providing a cause-based and comprehensive caries management philosophy that includes early caries detection, new caries lesions prevention, and management of carious lesions through minimally invasive procedures [12,13].Such a recent approach aims to preserve the tooth as much as possible to boost its life span by conservatively restoring it, converting the concept of "extension for prevention" into "prevention of extension" [14].However, caries management and restorative dentistry are becoming increasingly complex, putting clinical decision-making under increased strain due to innovations in techniques and materials, socio-demographic shifts, more knowledgeable patients, and abundantly available research [15].
In the last decades, the evidence-based practice concept has emerged in dentistry in responding to the imperative to improve the quality of standard patient care [16][17][18], which was recognized as making clinical decisions based on the integration of the best research evidence available with clinician expertise and patient values [19].In other words, an approach that assists healthcare practitioners in offering the best possible care to patients by integrating the best research with clinical practice.However, the responsibility of looking for, appraising critically, and interpreting research findings in daily practice should not be restricted solely to clinicians [20].In this regard, many organizations such as the International Caries Consensus Collaboration (ICCC), the American Dental Association (ADA), and the European Dental Association (EDA) have worked to develop recommendations for minimally invasive caries management, intending to improve dental care and maintain teeth healthy and functional for life [21][22][23][24].
Still, there is a big gap between research evidence and dental practice that leads to the loss of the evidencebased practice value in patient dental care [25,26], reflecting that many dentists still prefer to rely mostly on knowledge learned via education or personal experience, and many still need to embrace the concept of minimal intervention dentistry completely [27,28].Therefore, we aim to assess the knowledge of Egyptian dental practitioners about conservative caries management approaches and investigate whether this knowledge transfers into clinical practice and the barriers to translating research evidence into evidence-based practice.

Study design
This study followed the STROBE guidelines for reporting cross-sectional observational studies [29].The study protocol was a priori registered in the Open Science Framework and approved by the Research Ethics Committee, Faculty of Dentistry, Cairo University, Egypt [30].An online questionnaire was employed, and the survey was conducted during the spring of 2022.Participation was voluntary, and there were no rewards or penalties for participating.

Questionnaire
The questionnaire included several question styles (yes/ no questions, multiple choice questions, open-ended questions, and statements with Likert scale responses).After reviewing published cariology surveys, we designed these questions to assess three primary areas: knowledge (including evidence-based caries diagnosis and management according to the recent ICCC and ADA consensus [21,31,32], continuing education, and evidence-based practice (including enablers and barriers).We assessed the content validity of the initial questionnaire in person using a paper-based method, considering the differences in professions and education to guarantee that people from varied educational backgrounds would easily understand it.Intra-rater reliability was assessed on this pilot sample of ten participants who were academics, residents, and dentists, with one month between the test and retest.We used the Spearman correlation to test the correlation between the two rounds, and questions with low reliability were removed.The final questionnaire was transferred into a Google Form and distributed.
The questionnaire started with an overview of the study objectives and target population, highlighting that participation was voluntary.The subsequent questions focused on four areas (Supplementary file): • Demographic data (gender, graduation year, university, specialty, etc.) • Questions evaluating participants' knowledge and behavior toward caries management in terms of evidence-based practice.• Questions about participants' behavior toward continuing education and keeping up-to-date on cariology and restorative dentistry, as well as the barriers to doing so.• Questions about participants' attitudes towards evidence-based dentistry and their barriers to establishing an evidence-based practice.

Setting and participants
Convenience and snowball sampling were performed.We contacted university course directors, inviting them to complete and distribute the questionnaire to their residents, intern, and postgraduate students.Also, we used social media platforms to reach general practitioners and cover dental professionals throughout Egypt.The survey was opened in February and closed in June of 2022.We included graduated dentists with a bachelor's or higher degree from Egyptian universities who practiced in Egypt.We excluded undergraduate students and dentists who obtained their undergraduate qualification abroad or practiced outside Egypt.

Sample size
While World Health Organization (WHO) estimated the number of dentists in Egypt to be 32,848 in December 2018 [33], the Egyptian Dental Syndicate statistics assume this number to be 76,843 at present.As a result, we calculated our sample to represent a total population of 76,843 with a 95% confidence level and a 5% margin of error, resulting in a minimum sample size of 382.Sample size calculation was performed using Epi Info™ 7.2 (Centers for Disease Control and Prevention (CDC), Atlanta, USA) [34].

Statistical analysis
Descriptive statistics were used to present the demographic characteristics of the participants and their questionnaire responses as frequencies and percentages for categorical variables.Kruskal Wallis and Chi-Square tests were performed for group comparisons according to the respective data.Statistically significant differences were assumed if p < 0.05.All statistical analyses were performed using SPSS 28 (IBM.Armonk, USA).

Participants' demographic characteristics
Due to the nature of our recruitment methods (respondent-driven sampling), we could not estimate the total number of dental professionals who received our survey invitation.Among the 410 questionnaires received, 14 were excluded because they did not meet the eligibility criteria; ten obtained their bachelor's degree abroad, three were duplicated, and one had incomplete responses.1)

Knowledge towards caries management and restorative dentistry
Table 2 presents the results of the participants' responses to questions about knowledge and behavior toward evidence-based cariology and restorative dentistry.There was a significant relationship between specialty and total score of the questions evaluating participants' knowledge and behavior toward caries management in terms of evidence-based practice (p = 0.002), with restorative dentists having a higher median score (median = 16, IQR = 4.25) than oral medicine, pathology, and radiology specialists (median = 12, IQR = 3), oral and maxillofacial surgery and prosthodontics specialists (median = 14, IQR = 3.25), and general practitioners (median = 14, IQR = 4) (Appendix Table 1).However, there was a significant correlation between specialization and tools used to detect carious lesions (p < 0.001) since oral medicine, pathology, and radiology dentists (88.9%) used visual and tactile examination to detect carious lesions more than other disciplines, while academics (60.0%) used visual-tactile and radiographic examination.Additionally, the percentage of dentists who used caries-detector dyes to detect carious lesions was higher in endodontists (11.1%) than in other specialties; also, those who used recent diagnostic tools to detect carious lesions were higher in endodontists (7.4%) (Appendix Table 2).

Behaviors toward continuing education
Most participants agreed that there had been a significant change in the operative dental practice since graduation (78.8%), and 26.5% preferred the in-person courses and workshops to stay up-to-date with cariology and restorative dentistry (Table 3).However, there was a significant correlation between postgraduate education and the belief that there has been a significant change in the operative dental practice from graduation year (p < 0.001) since the dentists who believed that and pursued postgraduate education were 94.9%.Also, there was a significant correlation between that belief and years since graduation (p < 0.001), as 96.4% of dentists who believed that there had been a significant change in the operative dental practice had 10 to 14 years following graduation (96.4%) (Appendix Table 3).The main barrier to updating their cariology and restorative dentistry knowledge for 62.7% was that newly gained information would not be clinically applicable due to lack of equipment or working in a low-income area, while 58.3% of them stated the high cost of continuing education courses was the barrier.The American Dental Association (34.7%) was the top organization where participants usually followed its recent consensus and guidelines in cariology and restorative dentistry, followed by university curriculums (25.5%).

Attitudes toward the evidence-based dental practice
Most participants agreed that it is difficult to find a trusted source for evidence-based information (41.9%) and hard to understand the results of scientific articles due to the statistical portion (38.9%).They also agreed that the evidence-based information is time-consuming, not clinically applicable in daily practice (39.6%), and not clinically applicable due to the economic burden (44.7%).The main barrier to establishing an evidencebased practice in cariology and restorative dentistry for 32.1% of participants was the financial barrier, followed by the inability of participants to find trusted information (16.9%) (Table 4).However, there was a significant correlation between getting a trusted source for evidence-based information and postgraduate education (p < 0.001), as the participants who did not pursue postgraduate education and found it difficult were 43.4%; in contrast, those who disagreed and took a postgraduate education were 47.1%.Furthermore, there was a significant correlation between postgraduate education and the feeling that some evidence-based information is timeconsuming and not clinically applicable in daily practice (p = 0.001) since the participants who agreed with that and did not pursue postgraduate education were 45.3%; in contrast, participants who disagreed and took a postgraduate education were 30.4% (and 8.7% strongly disagreed) (Appendix Table 3).

Discussion
With the emergence of conservative and less invasive caries management approaches, it is crucial to assess dental practitioners' knowledge and attitudes regarding these strategies and how research can improve the quality of dental care.In this regard, this is the first study to assess Egyptian dental professionals' knowledge of current caries management approaches and investigate the barriers to translating this knowledge into daily clinical practice.Dental caries is a dynamic process with a recurring disease cycle involving demineralization and remineralization over time [35]; considering this modern concept in diagnosis and risk assessment are key underpins for successfully understanding and controlling dental caries.In this study, most dentists (59.1%) used G.V Black's classification in their dental practice, which means that their caries management was based solely on caries location without considering caries activity or lesion depth, potentially resulting in more invasive treatment [36].Although several systems were used to classify dental   caries, the International Caries Detection and Assessment System (ICDAS) has evolved to be more comprehensive and appropriate to current minimally invasive approaches, and current guidelines recommend it in clinical practice [22,37].This system classifies caries based on visual signs of the lesion severity considering sound surfaces and caries phases and combining these findings with radiographic data; hence, it aids in early caries diagnosis and assessment of complete caries prevalence [38][39][40].
Most dentists (about 80.8%) removed caries based on the feature of dentin hardness and color, and (about 67%) removed caries in small to moderate-sized cavities until hard dentine remained.Such behavior relies on the correlation between bacterial count and dentin hardness [41,42]; hence, removing caries until the remaining dentin becomes hard reduces residual bacteria at the cavity floor.Caries removal solely based on dentin characteristics regardless of the caries condition (i.e., active or arrest) results in over-treatments, removal of many arrested lesions, and complications if softened dentin is near the pulp [43,44].
The results revealed that most practitioners (more than 52.3%) still relied on the conventional approach of removing all soft dentine and considered step-wise excavation the best treatment for deep lesions (around 63.4%).Such an approach raises the risk of pulp exposure and issues; pulp exposure treatment is costly and may compromise tooth longevity; still, it is either invasive or unsuccessful in the long term [45][46][47].However, dentists continued to use this approach due to the incorrect belief that residual carious dentine or bacteria in the cavity could damage the pulp or cause caries progression [48][49][50].Moreover, the belief that step-wise excavation is the best alternative  to the complete excavation concept contradicts current evidence due to the high cost-benefit ratio and high risk of pulp exposure during the second visit [51,52].Without a doubt, the main goal of healthcare practitioners is to provide patients with the best possible care.Although several studies assessed dental students' and practitioners' understanding of conservative caries management approaches, they were focused mainly on the knowledge and its implication on daily practice [53][54][55][56].However, patient care will not improve unless this theoretical knowledge is applied in daily dental practice.Therefore, the real challenge in improving healthcare quality and implementing evidence-based approaches is not in evidence dissemination or knowledge but in translating this knowledge from research into evidence-based dental practice.As such, recognizing the obstacles is the first step toward implementing a dental practice based on research evidence, which includes hurdles related to the practitioner, evidence, context, and patient [57].23% of participants did not follow the caries management guidelines in their practices.Such behavior was primarily due to evidence-related barriers since 52% found it hard to obtain a trusted source, and 50% found it hard to understand the scientific articles' results due to the statistical aspect.Such a barrier is highly evident by the unmanageable amount of existing research (research waste); for example, there were 104,975 dental articles published between 2009 and 2019 on PubMed [58], making it impossible for dental practitioners to read, understand, and incorporate all this research into daily practice.Hence, resources that provide summarized intervention effectiveness reviews are crucial for promoting evidence-based practice.Another barrier is how results are often presented, emphasizing the significance of including a plain language summary with research articles.Moreover, it highlights the imperative of investigating the effectiveness of other means of research knowledge translation (e.g., videos, toolkits, and social media) rather than written materials in promoting evidence uptake in daily dental practice [59].
The main barrier for 62.7% of participants to update their knowledge was that the newly gained information would not be clinically applicable due to a lack of equipment or working in a low-economic area.This misconception stems from the common belief that evidence-based practice is synonymous with more scientific and expensive practice, contrary to the purpose of evidence-based practice: patient-centered and empirically grounded care to provide optimal clinical decisions [57,60].Such beliefs represent an evident gap between researchers' and practitioners' communities, as practitioners are unable to comprehend the complexity of the research process; on the other hand, researchers focus more on the quality of knowledge obtained from their studies, with little attention paid to the relevance of this knowledge for practitioners and patients, as well as the complexities of applying it in patient care [61,62].As a result, promoting evidence-based dental practice necessitates incorporating evidence assessment and synthesis skills in dental curriculum and training to ensure that the workforce will be filled with practitioners who can comprehend and use research evidence in their daily practices [63,64].Also, more extensive dissemination of easily accessible evidence reviews on clinical topics (e.g., scoping and systematic reviews and guidelines) can encourage interest in and promote applying research evidence in daily practice [65].Moreover, such a gap between the communities of researchers and practitioners can only be bridged by incorporating practitioners in the research process and giving them voices in determining the challenges and dilemmas they encounter and underpin their profession [57,66,67].
Patient-related barriers (i.e., economic, awareness, and social levels) were the major obstacles for participants in implementing evidence-based practice.Such barriers are rational and supposed to increase globally due to the rise in living costs and economic crisis, often affecting the patient's dental care and preferences [68,69].This emphasizes the crucial need to raise the value of dental research, prioritize future investigations, and advocate contextualized value-based dental care based on economic evaluation rather than effectiveness alone [70,71].
In other words, funding and publishing priority should be given to research that addresses a real-world issue that matters to patients and clinicians, with attempts to eliminate the research waste and repetition [72,73].This study has some limitations; first, this research is based on quantitative evaluations by collecting data using an electronic survey; hence, it could not provide a deeper understanding of the participant's knowledge and the barriers and enablers of implementing evidencebased dental practice in Egypt.Second, participants were recruited using non-probability sampling methods since this study was the first to be done about the cariology and evidence-based dentistry era in Egypt.Therefore, more population-based surveys and qualitative studies are needed to support these findings, provide a deeper grasp of the participants' knowledge and barriers and enablers of the evidence-based dental practice, and further explain the reasons behind their behaviors.

Conclusion
In Egypt dental practices, some conventional concepts (e.g., complete caries removal, using traditional caries classifications, removing caries based on dentin features and till hard dentine) remain prevalent, and practitioners' experience and familiarity are still predominant in shaping clinical decision-making.Practitioners could not utilize research evidence in their dental practice due to some patient-related (e.g., rising living costs and high cost of dental care) and evidence-related (e.g., difficulty understanding research results and inaccurate beliefs) barriers.As a result, it emphasizes the imperative of practically teaching dental practitioners in minimal intervention approaches through effective research knowledge translation means rather than written materials and guidelines, as well as the prioritization of dental research and advocating value-based dental care to address the economic crisis's impact on Egypt's healthcare.

Table 1
Demographic characteristics of the participants (N = 396)

Table 2
Participants' responses to questions about caries management and restorative dentistry

Table 3
Participants' responses to questions about continuing education in cariology and restorative dentistry

Table 4
Participants' responses to questions about their attitudes towards evidence-based dentistry