ABSTRACT
Introduction
Preformed metal crowns (PMCs) and pulpotomies are established treatments for carious lesions in primary molars. Despite their effectiveness, variability in knowledge and clinical experience amongst dental students has been reported. This study aimed to evaluate the knowledge and perceptions of Dutch dental students at the Academic Centre for Dentistry in the dental school of Amsterdam (ACTA). Regarding PMCs and pulpotomies in primary molars.
Materials and Methods
A cross‐sectional questionnaire study was conducted amongst second‐to‐final year dental students at Academic Centre for Dentistry in the dental school of Amsterdam (ACTA). The 23‐item questionnaire addressed knowledge, perceived curriculum coverage, and clinical/preclinical experience. Descriptive statistics and Spearman correlation tests were used (α = 0.05).
Results
Out of 120 invited students, 98 (81.6%) responded. While 75.5% of students considered the curriculum adequate for teaching PMCs, 84.7% felt that pulpotomies were insufficiently addressed. All students were familiar with the Hall Technique, and 50% had placed a PMC preclinically. Fewer students had clinical experience: 19.4% had placed a PMC and 9.2% had performed a pulpotomy. A positive correlation was found between preclinical and clinical PMC placement (Spearman's rho = 0.33, p = 0.0007).
Discussion
Whilst students received appropriate training regarding the use of PMCs, both in theory and practice, exposure to pulpotomy procedures remains limited.
Conclusions
Most dental students in Amsterdam demonstrated appropriate knowledge, preclinical experience and understanding of indications for PMCs compared to performing a pulpotomy. Therefore, greater emphasis should be placed on both the theoretical and practical aspects of pulpotomy.
Keywords: dental students, knowledge, preformed metal crowns, pulpotomy
1. Introduction
Dental caries is one of the most common diseases affecting individuals of all ages worldwide [1]. The WHO Global Oral Health Status Report (2022) indicates that 514 million children have cavitated carious lesions in their primary dentition [2]. Untreated carious lesions in children can have serious and lasting effects, potentially resulting in pain and infection, and in the long‐term, in decreased growth and body weight, poorer overall health, and a lower quality of life [3, 4]. Therefore, when carious lesions develop, early diagnosis and management are important. However, the treatment of carious primary molars may be challenging for dental practitioners due to the child's inability to cooperate with dental care and the differences in tooth anatomy between primary and permanent dentition [5, 6].
There are several treatment modalities available for managing carious primary molars. The philosophy of minimal intervention in paediatric dentistry has gained increasing attention, emphasising the preservation of sound tooth structure and the avoidance of unnecessary pulp exposure [7]. Restorative treatment options include direct restorations using resin composite, compomer, glass‐ionomer cement, or resin‐modified glass‐ionomer cement, as well as preformed metal (PMC) or zirconia crowns [8]. Within the framework of minimal intervention, selective caries tissue removal and sealing‐based approaches, often combined with the use of a PMC, have been recommended for managing deep carious lesions in primary teeth without clinical or radiographic signs of ‘irreversible’ pulpitis [9]. In this context, for primary molars with moderate to severe multi‐surface carious lesions and/or those that have undergone pulpal treatment, the placement of a PMC is often the preferred option [8, 9, 10, 11]. Nevertheless, pulpotomy remains a well‐established and widely accepted treatment when the pulp is exposed.
Traditionally, before a PMC is placed, non‐selective carious tissue removal and tooth preparation are required, usually with the use of local anaesthesia. However, a less invasive approach, the Hall Technique (HT), was first reported in 1997 for the management of primary molars with moderate carious lesions without signs or symptoms of irreversible pulpitis or sepsis [12]. Following this technique, a PMC is placed without the use of local anaesthesia, carious tissue removal, or tooth preparation [12, 13]. The effectiveness of the HT in managing carious lesions in primary molars is supported by a Cochrane review, which emphasises the success of lesion sealing‐based approaches compared to conventional restorative approaches [9].
However, in the case of deep carious lesions, when there is no radiographic evidence of a dentine bridge between the carious lesion and the pulp, or when carious tissue removal leads to pulp exposure in a primary tooth with a healthy or healable pulp, the placement of a PMC is not indicated [14]. In these scenarios, if there are no signs of inter‐radicular or periapical radiographic changes or pathologic root resorption, or pulpal pathology—such as clinical signs of infection (fistula, abscess), a pulpotomy may be considered an appropriate treatment option [15]. In this procedure, the coronal pulp is amputated, and the remaining vital radicular pulp tissue surface is covered with a biocompatible material [14].
Despite the high success rate of PMCs and pulpotomies, there is limited knowledge regarding the use of these treatment modalities amongst dental students [16, 17, 18, 19]. More specifically, previous investigations reported a lack of coherence between the theoretical and clinical curriculum in paediatric dentistry education [17, 18, 19]. Currently, there is limited information available regarding the knowledge, clinical experience and perceptions of dental students in the Netherlands concerning the use of PMCs and pulpotomies in primary teeth. Hence, the aim of the present study was to assess the knowledge, perceptions and (pre)clinical experience of dental students in Amsterdam, the Netherlands, regarding the use of PMCs and pulpotomies for managing carious lesions in primary molars.
2. Materials and Methods
The present cross‐sectional survey‐based study was approved by the Research Ethics Committee of the Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands (#2023‐12158). The questionnaire was created in the digital Qualtrics XM Platform, which was accessed through the Vrije Universiteit Amsterdam's Single Sign‐On (SSO) system. It consisted of 23 close‐ended questions, including multiple‐choice and five point Likert scale questions, in the Dutch language. However, for some questions, an ‘Other’ option was provided, allowing students to input their own answers in an open‐ended format. The questionnaire was based on a similar German study published in English and was modified by the current authors for the present study [19]. The questionnaire was translated from English into Dutch by a native Dutch speaker with advanced English‐language skills and subsequently back‐translated. The survey was pre‐tested on a convenience sample of 10 dentists who had graduated within the past two years to assess acceptability and feasibility. Survey modifications were made based on the feedback received.
The inclusion criterion for the present study was being a dental student in second‐to‐final year of study at ACTA. All eligible students who had completed the paediatric dentistry theoretical and clinical training component by January 2025 were invited to complete an online version of the questionnaire accessed via a QR code, which was available on the last day of the paediatric dentistry program. Information about the purpose of the research, the relevance of the study, the estimated amount of time to complete the questionnaire, and that participation was voluntary was provided. The students provided informed consent prior to completing and submitting the survey.
The survey consisted of an anonymised questionnaire divided into four parts: (1) general information about the curriculum of the paediatric dentistry course at ACTA; (2) the students' knowledge acquired during the education regarding PMCs and pulpotomies for the management of carious lesions in primary molars; (3) the students' clinical experience during their education regarding PMCs and pulpotomies; and (4) the students' perception of PMCs and pulpotomies for the management of carious lesions in primary molars. The English version of the questionnaire used in this investigation can be found in Appendix 1, Supporting Information, while the options provided and the correct answers are shown in Appendix 2, Supporting Information.
Statistical analyses were performed using SPSS version 27 (IBM Inc., NY, USA). Variables were analysed using descriptive statistics, and statistically significant correlations amongst the variables were tested using the Spearman correlation test due to the non‐normal distribution of the variables (α = 5%).
3. Results
A total of 99 out of 120 students (82.5%) responded, of whom 98 (81.6%) completed the questionnaire fully and were included in the analysis. All respondents reported that paediatric dentistry was taught as a separate course, and 96 (96%) mentioned that it was also taught as a (pre)clinical practical course. Whilst all respondents agreed that PMCs were included in the curriculum, 62 (63.3%) held a similar opinion about pulpotomy.
Regarding the current dental curriculum, 74 (75.5%) respondents reported that the use of PMCs in primary molars was covered adequately, whilst 83 (84.7%) indicated that pulpotomy was addressed insufficiently. Suggestions for improvement included more ‘hands‐on’ clinical training for PMC placement and performing pulpotomies, as well as more treatment planning discussions to help with understanding the indications of PMC placement and performing pulpotomies.
Regarding theoretical knowledge, all respondents were familiar with the HT. Furthermore, most students 54 (55%) selected PMC using the HT as the most suitable option for managing an asymptomatic primary molar in a cooperative child with either a healthy pulp or early‐stage reversible pulpitis, when the removal of carious tissue during treatment risks exposing the pulp (Figure 1). The majority of dental students 80 (82%) selected calcium silicate‐based material (Mineral trioxide aggregate or Biodentine) as the most indicated material for performing a pulpotomy (Figure 2), while most respondents (76; 78%) selected glass ionomer cement as the most indicated cement for PMCs in primary molars (Figure 3).
FIGURE 1.
Student knowledge of the preferred treatment approach for managing an asymptomatic primary molar in a cooperative child with either a healthy pulp or early‐stage reversible pulpitis.
FIGURE 2.
Respondents' selection of the most indicated material for performing pulpotomy in primary molars.
FIGURE 3.
Respondents' selection of the most indicated luting cement for preformed metal crowns (PMCs) in primary molars.
As for the main advantages of using PMCs in primary molars compared to resin composite restorations, 43 (42.6%) respondents considered the combination of reduced chairside time and better long‐term prognosis as the most significant benefits, whilst 34 (33.7%) selected reduced chairside time alone, and 7 (6.9%) better long‐term prognosis exclusively.
Regarding the main indications for using PMCs in primary molars, 51 (52%) respondents reported that extensive and/or deep carious lesions and tooth restoration after pulp treatment were the most common. However, 18 (18.3%) respondents added the child's high caries risk as an additional indication. No respondents reported that PMCs were considered aesthetic restorations. Eleven (11.2%) respondents indicated that PMCs were suitable for teeth with irreversible pulpitis, whilst 7 (7.1%) reported that PMCs were indicated for non‐cavitated carious lesions.
Considering the main indications for performing a coronal pulpotomy in primary molars, most respondents selected pulp exposure due to caries in teeth with a healthy or reversibly inflamed pulp as the principal indication (35.7%). A smaller proportion included cases of irreversible pulpitis or selected multiple indications (Table 1).
TABLE 1.
Respondents' choices regarding the main indications for performing a coronal pulpotomy in primary molars.
| Indication | Respondents number (%) |
|---|---|
| Pulp exposure due to caries in a primary tooth with a healthy pulp or showing signs and symptoms of reversible pulpitis and/or iatrogenic pulp exposure | 35 (35.7) |
| Pulp exposure due to caries in a primary tooth with a healthy pulp or showing signs and symptoms of reversible pulpitis (only) | 16 (16.3) |
| Pulp exposure due to a caries lesion in a tooth showing signs and symptoms of irreversible pulpitis | 10 (10.2) |
| Pulp exposure in a carious primary tooth with a healthy pulp or showing signs and symptoms of reversible pulpitis and/or pulp exposure due to a caries lesion in a tooth showing signs and symptoms of irreversible pulpitis | 10 (10.2) |
| Other | 27 (27.5) |
In terms of clinical experience, 49 (50%) respondents had placed a PMC preclinically using the HT; however, no respondents reported having performed a pulpotomy preclinically. Clinically, 19 (19.4%) respondents had placed PMCs using the HT, and 9 (9.2%) had performed a pulpotomy. Amongst respondents who had performed a pulpotomy, five (5%) experienced no problems, whilst the remaining four (4%) encountered haemorrhage control problems and inadequate cooperation of the child.
Regarding self‐perception of their knowledge of the indications and contraindications for performing PMCs in primary molars, 35 (35.7%) respondents reported a high level of knowledge, whilst 11 (11.2%) expressed a similar level of confidence regarding pulpotomy (Figure 4).
FIGURE 4.
Distribution of respondents' self‐perception regarding their knowledge of the indications and contraindications of pulpotomies and PMCs.
As shown in Figure 5, most respondents (93%) agreed that PMCs are a suitable option for asymptomatic primary molars with deep carious lesions. Fewer respondents considered PMCs 59 (60.2%) or pulpotomy 41 (41.9%) the preferred treatment for deep or extensive caries (Figure 5).
FIGURE 5.
Distribution of respondents' agreement/disagreement regarding statements over PMC and pulpotomy.
Concerning the correlations between the answers to the questions, one statistically significant positive correlation was found between the preclinical and clinical experience in the placement of PMCs (Spearman's rho = 0.33, p = 0.0007) (Table 2).
TABLE 2.
Correlation between answers to questions.
| Questions | What is the preferred treatment approach for managing an asymptomatic primary molar in a cooperative child with either a healthy pulp or early‐stage reversible pulpitis, when the removal of carious tissue during treatment risks exposing the pulp? | What are the main advantages of using PMCs in primary molars compared to resin composite restoration? | Have you ever placed a PMC using the Hall Technique in a primary molar? | Have you ever performed a pulpotomy in a primary molar? | Please select your level of knowledge about the indications and contraindications for using PMCs in primary molars. | Please select your level of knowledge about the indications and contraindications for performing a pulpotomy in primary molars. |
|---|---|---|---|---|---|---|
| Spearman's rho (p‐value) | Spearman's rho (p‐value) | Spearman's rho (p‐value) | Spearman's rho (p‐value) | Spearman's rho (p‐value) | Spearman's rho (p‐value) | |
| What are the main indications for using PMCs in the primary molars? | 0.12 (0.24) | −0.01 (0.88) | 0.13 (0.21) | 0.06 (0.58) | ||
| What are the main indications for performing a coronal pulpotomy in a primary molar? | 0.06 (0.54) | 0.31 (0.17) | 0.10 (0.31) | |||
| Have you ever practiced (pre‐clinically) PMC placement using the Hall Technique in primary molars? | 0.33 (0.0007) | |||||
| PMCs are a possible treatment option for asymptomatic primary molars with deep caries lesions but with a visible radiopaque zone of dentine separating the carious lesion from the pulp. | 0.10 (0.32) | |||||
| Pulpotomy should be the treatment of choice for primary teeth with extensive caries lesions but without evidence of radicular pathology when caries tissue removal results in pulp exposure. | 0.05 (0.61) |
Note: Bold = statistically significant.
4. Discussion
The aim of the present study was to assess the theoretical knowledge, perceptions and (pre)clinical experience regarding the use of PMCs and pulpotomy in primary molars amongst dental students in Amsterdam, the Netherlands. The vast majority of respondents reported that the current dental curriculum covers the use of PMCs sufficiently. This is putatively related to the fact that PMCs are not only explained in detail during the theoretical course but are also taught in preclinical training; more specifically, the procedure of placing PMCs, either conventionally or using the HT, the cementation process, and the indications for their use are discussed in theoretical sessions. In terms of preclinical experience, the placement of a PMC using the conventional technique, which involves tooth preparation, and the placement of orthodontic separators when using the HT, are both requirements of the course. Interestingly, only 50% of respondents reported having practiced PMC placement preclinically, specifically using the HT. This implies that all respondents practiced the placement of PMCs according to the conventional technique, while half of them additionally practiced the HT, further supporting the statement that PMCs are covered adequately in the curriculum. Similarly, in the study of Santamaria et al., German dental students were taught the importance of PMCs and were familiar with the HT, but their practical education was limited [19]. In a comparable study amongst UK dental schools, it was found that the HT for the placement of a PMC was taught theoretically, but its clinical application was not implemented consistently [16]. Likewise, another study carried out in Iran found that HT was not taught consistently [17], despite it being a gold standard approach in paediatric dentistry [20].
Regarding PMC cementation, almost 80% of the respondents selected glass ionomer cement for the luting cement, which is the preferred material taught during both the theoretical and preclinical components of the course. This indicates that the curriculum reinforces evidence‐based clinical practice effectively, ensuring that students apply their knowledge according to best current practice [11, 12]. Regarding the main advantages of using PMCs in primary molars compared to resin composite restorations, the less chairside treatment was the most frequently cited benefit. Although the specific technique was not indicated in the questionnaire, it is putatively assumed that the respondents were referring to the HT.
In response to the question regarding the preferred treatment for an asymptomatic primary molar with a healthy pulp or early‐stage reversible pulpitis—where carious tissue removal risks pulp exposure—over half of the respondents selected placement of a PMC using the HT. However, literature indicates that the HT is contraindicated in cases lacking radiographic evidence of a dentine bridge or showing signs of pulpal exposure clinically or radiographically [12]. A recent retrospective study also reported higher failure rates, leading to extraction, when PMCs were placed on teeth with carious lesions extending to the inner third of the dentine [21]. Therefore, pulpotomy was considered the correct answer to this question. The respondent's preference is putatively influenced by greater theoretical and preclinical emphasis on PMC placement compared to pulpotomy technique, which may also explain why 60% agreed that PMCs should be the treatment of choice for deep carious lesions in primary molars.
Almost 85% of the respondents expressed that the current dental curriculum did not cover the pulpotomy technique adequately. This can be explained by the fact that although the procedure is covered theoretically, it is not included as a preclinical exercise. As pulpotomy is not a preclinical requirement, a possible consequence is that students may not feel confident in performing this procedure on primary molars after they graduate. A recent similar survey in Australia found that the final‐year dental students also lacked clinical confidence in performing pulp therapies on primary teeth [18]. In contrast, a comparable study amongst UK dental schools reported that all students were taught the technique of pulpotomy preclinically in a simulated environment [16].
Concerning pulpotomy medicaments, several materials have been identified as potential options. According to a recent systematic review and meta‐analysis, MTA had the highest success after 24 months, with a mean success rate of 98.2% for clinical and 93.8% for radiographic success [22]. Biodentine showed no significant difference compared to MTA [23]. In the current study, almost 82% of the respondents selected calcium silicate‐based materials (MTA or Biodentine) as the preferred medicament. This alignment with the literature indicates that the students were well informed about best practices for pulpotomy medicaments, despite feeling less confident in their theoretical knowledge of the procedure.
Regarding clinical experience, neither of the treatment modalities was frequently performed by the dental students. The low percentage of respondents who clinically placed a PMC (19.4%) and performed a pulpotomy (9.2%) in a primary molar can be attributed to the limited number of paediatric patients who are available for treatment in the university setting. Additionally, the patient population treated by undergraduate students in the university in Amsterdam consists primarily of adolescents, whereas younger patients are mostly managed by specialist trainees in paediatric dentistry. As a result, undergraduate students have limited opportunities to gain clinical experience with PMCs and pulpotomies. In relation to the pulpotomy technique, a further reason for the limited number of procedures performed by students may be the decreased number of clinical indications, as a result of the shift towards selective caries tissue removal and the implementation of non‐invasive or less invasive treatment approaches [9].
With regard to the correlations between the answers to the questions, a statistically significant positive correlation was found between the preclinical and clinical experience in placement of PMCs. This may be explained by the fact that the preclinical training provides a foundation for clinical practice, giving students the confidence to perform the treatment in a clinical setting, or simply that the opportunity arose during clinic sessions. However, the correlation was weak, likely due to the low number of paediatric patients treated during the course, which results in limited opportunities for the students to apply what they have learned in the preclinical setting. A study from the University of the Western Cape in South Africa highlighted that preclinical simulation laboratories enabled dental students to apply theoretical knowledge practically, thereby enhancing their clinical skills and confidence [24]. Additionally, the Association for Dental Education in Europe (ADEE) has discussed the transition from preclinical to clinical training, emphasising the importance of this foundational phase in preparing students for real‐world clinical scenarios [25].
The present study had several strengths and limitations. Firstly, a key strength was the high response rate (81.6%), which minimised the risk of non‐response bias, providing a more reliable representation of the results. Furthermore, it was the first study to assess the knowledge and perceptions regarding the use of PMCs and pulpotomies in primary molars amongst dental students in the Netherlands. As a result, these data could be used as a baseline for further research on this topic and contribute to the ongoing development and improvement of the curriculum. On the other hand, a limitation of the study was that the data were only from dental students in Amsterdam and did not include the other two dental schools in the Netherlands. Consequently, the results may not be generalisable to the entire country. However, anecdotally, the paediatric dentistry curriculum across these three dental schools is broadly comparable.
The results of the present study suggest that a stronger focus on both theoretical and clinical aspects of pulpotomy during the undergraduate curriculum could potentially enhance the quality of paediatric dental care provided by general dentists, who are typically the first point of contact for children in the Netherlands. The current curriculum of the Paediatric Dentistry course at ACTA includes weekly theoretical and (pre)clinical modules for all the second‐to‐final year dental students for a period of half an academic year. A potential improvement would be to include pulpotomy training in the preclinical modules. Moreover, increasing the frequency of treatment plan discussions during the theoretical modules could further strengthen students' theoretical knowledge of the indications for performing a pulpotomy. While this study focused specifically on pulpotomy and the use of preformed metal crowns in the management of carious primary molars, a more comprehensive evaluation of students' understanding of the full range of minimally invasive and other caries management strategies would be valuable for future research. Such broader investigations could help identify additional educational needs and guide further curriculum development to better prepare students for evidence‐based management of caries in paediatric patients.
5. Conclusion
Most dental students in Amsterdam had appropriate knowledge, preclinical experience and understanding of when to place a PMC; whereas most dental students would benefit from more education and experience for performing a pulpotomy. Therefore, greater emphasis should be placed on both the theoretical and practical aspects of pulpotomy.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1: eje70081‐sup‐0001‐Supinfo01.docx.
Data S2: eje70081‐sup‐0002‐Supinfo02.docx.
Acknowledgements
We are grateful to all second‐to‐final year master dental students (2024 and 2025) of the dental school of Amsterdam (ACTA) for their participation in this study. We would like to express our gratitude to Prof. Dr. Ir. Monique van der Veen for the translation of the questionnaire and our colleagues for their feedback regarding the questionnaire during the pilot phase of the study.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: eje70081‐sup‐0001‐Supinfo01.docx.
Data S2: eje70081‐sup‐0002‐Supinfo02.docx.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.