Are current methods of managing carious primary teeth effective?

Dafydd Evans Dundee Dental Hospital & School 4th October 2002

Primary teeth; some relevant facts

there are 20 of them
the last one may not be shed until 11-12 yrs and the factor at the root of the problem small teeth, big pulps

Dental decay is common

dmft
> 3.0 2.51-3.0 2.01-2.5 1.51-2.0 1.01-1.5 < 1.0

BASCD 1999/2000 survey 5 year olds

Yes, it is skewed, with 25% of children having 75% of the decay, but still.
55% of Scottish 5 years old have decay
SHDEP 1998

16% of Scottish 5 year olds have had at least one extraction SHDEP 1998 42% of Scottish 8 year olds have had at least one extraction
Childrens Dental Health in the United Kingdom, 1993

Management options for carious primary teeth

leave unless/until problems

prevention alone, and leave etc

prevention plus interventive treatment of some sort

So whats the evidence supporting any of the above?

Chocolate; its time to look at the health benefits

Evans D, Cadbury J & Rowntree M Journal of Wishful Thinking 2001; 184;48-52

Conclusion There is a positive association between consumption of chocolate and life span

British Society for Childrens Dentistry

there is the possibility of bias and confounding factors in the study samples, and the results, although interesting, should be interpreted with caution
Atheroma Review

this is a dreadful piece of work

Study data
Annual chocolate Lifespan consumption per capita Sample A Sample B 13 kg 2.5 kg 75-80 yrs 65-70 yrs

Sample C

0.16 kg
Significance p<0.001

60-65 yrs

(Pratt & Whitney Anyportinastorm test)

Evidence for the effectiveness of dental treatment

The 5-year results of a clinical trial comparing a glass polyalkenoate (ionomer) cement restoration with an amalgam restoration. Welbury R R, Walls A W G, Murray J J, Mccabe J F. Br Dent J 1991; 170: 177-181 The use of a reinforced glass-ionomer cermet for the restoration of primary molars: a clinical trial. Kilpatrick N M, Murray J J, Mccabe J F. Br Dent J 1995;179:175-179 The fate and survival of amalgams and PMCs fitted in specialist practice. Roberts & Sherrif Br Dent J 1990 169:237-244

Dental treatment can be effective, but is it effective in primary care?

Care index

1983: 15% 1989: 18% 1993: 8%

1999: 9%

Scottish DPB Annual Report 1998/1999

155,474 extractions (under 18) 219,891 fillings 513 PMCs fitted 2,045 vital pulpotomies 5,303 non-vital pulpotomies 11,714 Gas (under 18) 2,118 sedations (under 18)

Dental treatment can be effective, but is it effective in primary care?

The fate of the carious primary teeth of children who regularly attend the general dental services
Tickle M, Milsom K, King D, Kearney-Mitchell P & Blinkhorn A Br Dent J 2002 192:219-223

The fate of the carious primary teeth of children who regularly attend the general dental services Tickle et al Br Dent J 2002 192:219-223
Retrospective case study of 677 children, with 13,540 teeth, under the care of 50 GDPs 1,789 teeth extracted, but only 475 due to pain/ sepsis >80% of carious primary molars filled Conclusions no difference in the proportions of teeth extracted due to pain or sepsis whether a carious tooth was restored or left unrestored

The fate of the carious primary teeth of children Tickle et al Br Dent J 2002 192:219-223
Three hypotheses offered as an explanation of the findings: There really is no advantage in restoring primary teeth The quality of treatment provided by the GDPs is no better than leaving the teeth unrestored GDPs are actively deciding which teeth to restore and which they can leave unrestored to reach the same result, which is exfoliation The authors favour the latter (BDJ 192; 671)

The fate of the carious primary teeth of children who regularly attend the general dental services Tickle et al Br Dent J 2002 192:219-223
Retrospective case study of 677 children, with 13,540 teeth, under the care of 50 GDPs 1,789 teeth extracted, but only 475 due to pain/ sepsis >80% of carious primary molars filled Conclusions no difference in the proportions of teeth extracted due to pain or sepsis whether a carious tooth was restored or left unrestored The bulk of carious teeth exfoliated naturally irrespective of whether they were filled or not

The fate of 1,587 unrestored carious deciduous teeth; a retrospective general dental practice based study from northern England Levine R, Pitts N & Nugent Z. Br Dent J 2002 193:99-103

Retrospective case study of 1,587 unrestored carious deciduous teeth in 481 children, in 2 GDP practices
82% of untreated carious teeth exfoliated without causing pain (if the 178 teeth extracted prophylactically not included with the 190 extracted because of pain) Conclusions The carious teeth most likely to cause symptoms were carious molars with pulpal involvement in 3 year olds The majority of unrestored carious deciduous teeth remain symptomless until shed.

The majority may well exfoliate naturally, but.

16% of Scottish 5 year olds have had at least one extraction SHDEP 1998 42% of Scottish 8 year olds have had at least one extraction
Childrens Dental Health in the United Kingdom, 1993

50% of children remember having toothache

The prevalence of pain and impact of pain in 8 year olds in Harrow, England. Shepherd M, Nadonovsky P & Sheiham A B Dent J 1999;187:38-41

If too many teeth are being extracted, and fillings work, wheres the complexity?
In some parts of the UK, the care index for 5 year olds can rise to 37%
In Quebec, dmft 1.77, CI 65%

In Grampian, dmft 1.89, CI 15%

If too many teeth are being extracted, and fillings work, wheres the complexity?

Daniella
5 years old Referred for GA extractions

Daniellas treatment
Prevention
Non-vital pulpotomy 65, and vital pulpotomies 64 and 84

PMCs 64, 65, 84 & 85

Filling 55

And the complexity?

Granny
GDP Fees Radiographs, fear of failure, pressure of work,etc. etc.

Alternative restorative techniques

Caries removal Laser ART Carisolv Air abrasion Arresting caries Silver fluoride/ stannous fluoride Duraphat Saucerisation/ discing/ fenestration Chewing gum Copper phosphate cement

Sealing in caries GIC/ composite/ fissure sealant Hall Technique

Copper phosphate cement

Copper Phosphate Cement failure rate at 6 months

% failure rate

73.1

88.9

Cl. I

Cl. II

Foley et al. Health

Bulletin 2000

Copper Phosphate Cement

20

Solubility
BCC

% weight loss

15
10 5 0 0 100 200

Chemfil
300 400 dys

Foley et al. Eur J Prosthodont Rest Dent 2002

Copper phosphate cement

Conclusion It is significantly more bactericidal than other restorative materials Solubility precludes its use, even as a lining material

The Hall technique

The Hall technique: a pilot trial of a novel use of preformed metal crowns for managing carious primary teeth. Evans, D.J.P., Southwick,
C.A.P., Foley, J.I., Innes, N.P., Pavitt, S.H. , and Hall, N. Tuith 2000

www.dundee.ac.uk/tuith

Two Year Audit, Hall Technique, 111 crowns fitted

Preformed crowns
Still present or naturally exfoliated Fell off; tooth filled conventionally Extracted Crown removed as child unable to tolerate it Total 111 100%

No.
91 3 16 1

%
82 3 14 1

N Hall

Pilot Trial: Crowns Fitted

Dentists
GDP 1 GDP 2 GDP 3 GDP 4 Hosp 1 Hosp 2

Recruited
10 10 4 0 10 10

Fitted
10 10 3 0 10 10

Hosp 3
Hosp 4

4
1 49

2
0 45

Time Taken to Fit Crown

Time < 10 min % 68%

< 10 min
< 15 min

89%
96%

Amount Bite Propped Open

mm %

0 11%

1-2

2-3

3-4 11%

5-6 2%

73% 2%

Dentist Assessment of Discomfort Experienced by Children

No apparent Discomfort Very mild, almost trivial Mild, not significant Moderate, but child coped Significant and unacceptable

61%

24%

15%

0%

0%

Hall technique
analysis of Dr Halls practice records showed that 978 crowns had been fitted since since 1988
for all tooth types there was over 76% probability of the crown surviving for 1000 days and over 60% probability for 2000 days highest failure rate was with Ds

Hall technique
Conclusion promising, not recommended for use until study results are known (around December 2003)

Possible ways forward

Better funding More training

Alternative techniques
More research into impact of restoring/ non restoring carious primary teeth Patient and parent education Reappraise role of CDS

Therapists
and finally

best of all would be to stop trying to mop up the floor and start turning off the tap! Caries prevention 0-5 yrs