December 09, 2019

Great new information on the management of child dental decay

You will have spotted that this post is not about orthodontics. I have decided to write about a groundbreaking trial that provides us with great information on the management of child dental decay.  Everyone involved in dental care should read this. So please share this as much as you can.

This post is about a study that evaluated three methods of managing primary tooth caries.

Dental caries is the most common childhood disease. Surprisingly, there is a large amount of uncertainty about its management.  This new trial investigated this common clinical dilemma. A UK based team did this trial. The Journal of Dental Research published the paper.

What did they ask?

They asked the following clinically relevant question;

“What is the best way of managing primary tooth caries”?

What did they do?

They did a 3 arm parallel-group RCT with a 1:1:1 allocation of patients.  The main details are:

Participants:3-7-year-old children who were attending general dental practice with at least 1 primary tooth carious lesion extending into dentine.

Interventions:  (i) Prevention alone (ii) conventional with best-practice prevention and (iii) Biological treatment with best-practice prevention.

Outcome:  (i) The proportion of participants with at least one episode of dental pain and/or infection.  (ii) The total number of episodes of dental pain and/or infection for each participant.

The trial was run in a sample of 72 UK  general dental practices.  1,144 children were randomised to one of three interventions.

  • PA (Best practice prevention alone)

This involved:

Dietary investigation, analysis and relevant advice.

Tooth brushing with fluoridated toothpaste and mouth wash.

Topical fluoride application

Fissure sealants of secondary teeth.

 

  • Conventional with best-practice prevention (C+P)

Local anaesthetic, complete removal of caries and restoration.

 

  • Biological with best-practice prevention (B+P)

Sealing in carious tooth tissue with adhesive tooth tissue or a preformed metal crown with the Hall technique.  LA was not routinely prescribed because this was not necessary.

They recorded the final outcomes after a median period of 34 months.

They did a relevant sample size calculation. Randomisation was done via a remote web-based system.  Parents, participants and dental professionals were not blinded to the allocation.  However, they analysed the data blind with the relevant modelling techniques.

What did they find?

Importantly, they analysed the data with an intention to treat analysis for 1058 participants.

At baseline, there were no differences between the groups.

They presented data on the co-primary outcomes of  (i) proportion of dental pain and/or infection or (ii) number of episodes of dental pain/infection.  I have put their data in this table.

 Intervention  
PreventionCaries removalBiological control
Proportion with dental pain (%)454240
Number of episodes of pain (n)0.620.580.72

They also measured cost-effectiveness, participants quality of life or any other outcomes.

Importantly, the authors pointed out that for all three interventions that they tested the incidence of complications was high. As a result, we should concentrate on the prevention of childhood dental decay.

Their overall conclusion was:

“There was no evidence of a difference in clinical effectiveness between the three interventions”.

What did I think?

I thought that this was a significant research project that answered a clinically relevant question about the treatment of child dental decay.  The study was large and well carried out.  It was difficult for me to find any significant deficiencies in their methodology.  I am confident that the results will change clinical practice.

What does this mean clinically. If I were to treat a child with caries in their primary teeth, I certainly would avoid LA and  mechanical caries removal, as this is very invasive for a young child. There may be some advantages in biological caries control, but these are not large. Maybe the best treatment is to provide prevention with no other intervention?

This paper provides excellent information that enables all dental carers to explain the risks and benefits of primary tooth caries treatment to our patients.  I will be back to orthodontics next week.

 

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Have your say!

  1. Avatar

    Thank you Kevin. Something to really get our teeth into. A challenge to heavy-handed expensive dentistry.

    There are so many GAs with multiple stainless steel crowns done, partly to maintain space, and mainly to “improve” the dental health of children. It certainly keeps the paedodontists busy. These interventions, combined with space maintenance, often cost half of a full course of fixed treatment. And the benefit for patients? Especially when a full course of fixed treatment will be required, regardless of the restorative assault.

    I wonder whether evidence will change clinical practice in this field, as it has little influence in orthodontics.

  2. Avatar

    Kevin, thank you for appraising a very important paediatric paper. Could I please ask that you consider highlighting the lack of radiographs taken (<50% of participants at any point in the trial) which will inevitably have lead to under diagnosis and, although this wouldn’t necessarily affect the differences between arms, would go some way to explaining the worryingly high rates of pain and infection in all arms.
    As a paediatric dentist, my take away message from this study is that once caries is clinically visible in primary molars the outcomes are poor no matter what we do. We need to consider why all of our management options have such poor success rather than just choosing one of the bad options. In an ideal world I don’t think this should mean the end of operative management of caries in primary molars but I do think it should guide us towards early prevention, early diagnosis using radiographs and earlier intervention for carious lesions in primary teeth. I realise there are multiple clinical and organisational barriers to providing early high quality paediatric dentistry especially to those most at risk but these should be our guiding principles.

  3. Avatar

    Does the study take into consideration the issue of space maintenance and its importance?

    • Avatar

      Space maintenance is an interesting topic that is rarely evaluated with an evidenced based approach. It is generally based on what one was “taught” as an undergraduate or postgraduate.

      Little is generally understood about how and where space is lost. Even less is known about whether space maintainers provide any benefit for the patient, but they are still widely used. A paedodontist told me that they are used routinely whenever a primary molar is lost early – a formula that provides maximum benefit for the practitioner, and removes the tedious demands of diagnosis.

      As every orthodontist knows, any space “lost” can be regained quickly, without any additional cost or adverse consequences, when comprehensive orthodontic treatment is undertaken. If orthodontic treatment will be required, then a space maintainer should not be used! This should also be the case when stainless steel crowns or pulpotomies are considered, as the above article indirectly illustrates.

      Here is an interesting article on how and where space is lost (Am J Orthod Dentofacial Orthop 2011;140:771-8). And this one has wonderful conclusions (Int J Paed Dent. 2009;19(3):155-62).

      I’ve run out of space 😁 and I’m lost for words!

      • Avatar

        I don’t think any space loss can quickly or efficiently regained when doing comprehensive orthodontics. Mesial drift of the lower permanent molars due to early loss of the mandibular E’s or D’s is difficult to regain, especially if regaining the lost space is delayed until comprehensive braces. Also, this space loss often results in the loss of permanent teeth later (premolar extractions) when comprehensive orthodontics is initiated due to the large amount of crowding due to space loss and the difficulty and time required to distalize the lower permanent molars.
        Maintaining arch form and symmetry in the primary and mixed dentitions will decrease the orthodontic demand in the future, and is key in orthodontic efficiency when comprehensive therapy is done.

      • Avatar

        E,s are a perfectly good space maintainer in most cases.Formal space maintainers are generally a waste of time and money and just serve to milk insurance plans that could be used for comprehensive ortho.

      • Avatar

        “As every orthodontist knows, any space “lost” can be regained quickly, without any additional cost or adverse consequences, when comprehensive orthodontic treatment is undertaken.”

        In general agreement however premature loss of the 2nd deciduous molar either from caries or ectopic 1st molar eruption and subsequent ectopic 1st molar eruption can create a more difficult situation and “quickly regained” not so easily achieved.

        Space maintainers frequently maintain insufficient space or excess space. The fixed maintainer, an iatrogenic nidus for bacteria in a likely caries prone patient by history, is not predictably passive in my experience. Masticating against a unilateral Band&Loop can cause tipping of the tooth to which it is attached. A bilaterally affixed space maintainer if not absolutely passively placed can cause expansion, constriction, rotation. A bilaterally affixed maintainer can cause eruption of one side and intrusion, with concomitant tipping (moment of the forces), if overseated on one side. Patients that present with such fixed appliances have more problems from the appliances than benefit in my opinion.

        Rarely/never do I see any advantage to intra-arch space maintainers except for that danged 2nd_deciduous_molar/permanent_1st_molar area and then only if the 2nd premolar is not erupted to where it will act as its own space maintainer.

        I can’t remember the last time I’ve recommended a space maintainer it is that rare.

  4. Avatar

    As a practicing clinician, the most difficult thing I tried to do was to change the behaviour of patients towards maintaining better oral health.
    There were so many balls in play! Whether the patient liked me. The expectations of the family. The family’s expectations of dentistry, to mention only three.
    I remember asking a very experienced colleague – a Paediatrician – whether his patients took any notice of his advice (and of course, he was playing for much higher stakes than I). His answered that if his advice agreed with Granny’s opinion, the family and patient would do what he told them but if he disagreed with Granny, well …
    Concerning this study, I wonder if there is any information about the social mix of the practices and the expectations of the patients and parents at the start?
    My experience is that patients who come with active caries, high plaque scores and a less than satisfactory diet, will take to a purely preventive regime less successfully than those who come from a more-advantaged back ground.
    It would be encouraging if research demonstrated that times have changed.
    Is there any who can help me?

  5. Avatar

    Thank you for posting this intresting article.

    My question to you Sir :

    Is pain episodes, propotion of pain and …. ,objective measurements to measure the the outcome ?
    What was the effect size ?

    My clinical implication of this scientific papper , is to emphasize the best practice prevention method during the orthodontic treatment.

  6. Avatar

    Very important paper.

  7. Avatar

    The aim of treating childhood caries is to prevent infection, preserve the space for permanent teeth and reduce risk of decay to permanent teeth as decay is an infectious disease. Reduction of pain is not in my opinion an important factor in determining if treatment is successful. Prevention is good if there is cooperation from the family community but unfortunately the kids most at risk are those who dont have that. I believe BOTH prevention and treatment are needed.

    • Avatar

      Agreed. I’m a community health pediatric dentist. Prevention alone sounds lovely… if parents listen AND are in control of their household. Just like ortho often likes non-compliance appliances. Crowns mean I can protect a kid while I can work on the parents who haven’t yet bought into the idea that their kid could NOT have crappy adult teeth one day if we just change some behaviors. There’s a reason Pediatric Dentistry is often nicknamed “Parent dentistry”. I do a lot of SDF and hall crowns, but I still do conventional when kids tolerates because of better fit and retention and often, the prick of LA is better tolerated than the 24 hours of high interdental pressure from ortho seps or just going straight for the hall crown day 1 – Especially for younger kids. Conventional restoration is best also and especially when I’m doing 2 adjacent molars and/or half mouths. I’ve certainly Halled all 4 Ds on kids in 1 visit, but when I have kids with more than half of their teeth having advanced caries at 4-5 years old, you bet your ass I’m going to the OR. This article is important, but certainly does not mean we should only be doing prevention, or only be doing hall crowns. I do a lot of band and loops and distal shoes. Not every parent can afford y’all’s fees for fixed ortho. Based on some comments here about bilateral spacers, I’d be curious to learn more about the purported harms… 7 year old who needs both Es out… I’d do an LLHA over bilateral B&Ls, but I guess you tell me

      But don’t be so ready to proclaim evil intentions from your Pedo colleagues who don’t hang up their hat upon reading this article

  8. Avatar

    Two comments on a very informative study that was brought to our attention.
    1~We all agree with prevention but if ,as under the NHS ,tmnt.is provided at no cost at point of delivery does this encourage “lazyness” and accessing invasive care when prevention should have been practised? Of course there are many disadvantaged \ children at risk from low socioeconomic levels who will never be guided towards prevention.
    When socialised dentistry was offered in my area of Canada ,the utilisation rate was 50%.This leads me to the conclusion that a significant proportion of the public does not value dental health and certainly does not see it as health care !This comes as no shock to us,I know.
    2~This paper really puts into perspective the use of pediatric dental GA. There have been several “accidents “ and ensuing legal actions in Canada regarding this ie.GA,s.for routine dental care in children.In Canada ,expensive and limited OR time is clogged up with pediatric dental cases.
    I have no easy answers just major concerns !!

  9. Avatar

    I would like to give my opinion as a paediatric dentist. This study was commissioned in order to address the issues around whether primary teeth should be restored or not and if so how? The outcomes for both biological and conventional interventions were similar, which could easily lead one to the conclusion that biological interventions could be implemented widely in practice. But on reading the results carefully it is clear that this would not be a justifiable conclusion. There were a high percentage of children in the study who experienced episodes of pain through the follow-up period in all arms of the study. Please remember that the dentists who participated in this study were trained specifically in the provision of the three treatment protocols. Despite this they could not provide a pain free journey for a large percentage of children in their care through the study period.

    For years dentists in the UK have been burdened by two issues, poor remuneration for treating those children who still get extensive caries, and lack of confidence in providing restorative treatments that have a chance of lasting for a few years unlike the “thumb print” restorations that are shoved into cavities. For this reason UK dentists in particular have always searched for reasons which would justify either not providing restorative care, or providing restorations that could be done without having to learn behaviour management or advanced skills for treating children. FiCTION hoped to provide a platform for implementation of biological approaches in the NHS which fulfils the later. Clearly it has not fulfilled that aim as it is clear that despite additional training a pain free journey for a large percentage of children was not provided with either approach.

    For many years now Orthodontics as a speciality, recognising the limitations of general practitioners in provision of “safe” orthodontics, decided to limit the orthodontic education in the undergraduate curriculum, thereby shifting orthodontic care firmly into the specialist domain. Thousands of children attending NHS practices in the UK have untreated dental caries, and also poor restorative care. It is well recognised and of course highly publicised in the media the number of children who are subjected to General anaesthesia for exodontia, which in my opinion is a highly unacceptable state of affairs in a developed country. I have often called this a matter of national Shame. FiCTION showed that despite advanced training good outcomes cannot be achieved in general practice for all children who are still unfortunate enough to get extensive caries. Perhaps, like Orthodontics did several years ago, we need to carefully consider whether most children with extensive caries will benefit from specialist care rather than this on-going debacle which is constantly making headlines in the media for all the wrong reasons. A much bigger role for specialist in paediatric dentistry in provision of routine care for children with dental disease needs to be considered rather than persisting with patchwork care with poor outcomes that is currently the norm in the NHS.

    • Avatar

      Briefly as a response I understand that the lack of ortho.teaching at the undergrad .level is due to the inability of universities to attract qualified orthodontists to teach.
      Also ,having seen many behavioural management techniques at work ,I doubt that the terrific time investments needed are financially sustainable.I well remember a dedicated pediatric dentist demonstrating such techniques by completing an occlusal amalgam on a very difficult child in 65 mins.
      These concerns are only going to get worse as misguided groups campaign to have Flouride removed from water supplies !

  10. Avatar

    An interesting synopsis and some very interesting points in the comments, especially regarding the disgrace of the number GAs.

    “Maybe the best treatment is to provide prevention with no other intervention?” Treatment was provided for lesions into dentine. I am not a specialist, but if those lesions were cavitated I would certainly not rely on prevention alone, nor would I want that for my children. Fortunately Hall Technique PMCs offer an excellent alternative to LA and a conventional restoration. They do have some significant advantages and few drawbacks e.g. colour. Some children also cope well with LA. It depends…

    The big battle is that against the marketing might of the soft drinks and confectionery companies.

  11. Avatar

    “However, when considering the slightly higher number of episodes of dental pain and infection in the prevention-alone group, and the overall cost of subsequent treatment, the sealing in with prevention strategy was the most cost-effective treatment.”

    https://theconversation.com/tooth-decay-in-children-is-it-time-to-put-the-needle-and-drill-away-129466?fbclid=IwAR1CQdB-Rp3A_S9_qRgqtW0ng–jVkmOHdMPfITkuuUJejV65PRbZjPWH_w

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